HEALTH DEVELOPMENT FUND

Programme Document for a Multi-donor Pooled Fund for Health in (2016-2020)

A Coordinated Effort by the Government of Zimbabwe and Development Partners in supporting the Ministry of Health and Child Care to im - prove equitable access and quality of in Zimbabwe, with special em - phasis on Women, Newborns, Children and Adolescents

August 2015

Supporting the National Health Strategy EAL Y H TH R A C A to improve access to quality health M I R Health R E

P

M care in Zimbabwe

E I A N Development Fund N R I H S O A T E I C R A T Y L A D O T H Y N IL F CH HEALTH & Z IMBABWE Canadian International Development Agency

HEALTH DEVELOPMENT FUND

Programme Document for a Multi-donor Pooled Fund for Health in Zimbabwe (2016-2020)

A Coordinated Effort by the Government of Zimbabwe and Development Partners in supporting the Ministry of Health and Child Care to im - prove equitable access and quality of health care in Zimbabwe, with special em - phasis on Women, Newborns, Children and Adolescents

August 2015

Supporting the National Health Strategy EAL Y H TH R A C A to improve access to quality health M I R Health R E

P

M care in Zimbabwe

E I A N Development Fund N R I H S O A T E I C R A T Y L A D O T H Y N IL F CH HEALTH & Z IMBABWE Canadian International Development Agency

Foreword

A Coordinated Effort by the Government of Zimbabwe and Development Partners in supporting the Ministry of Health and Child Care to improve equitable access and quality of health care in Zimbabwe, with special emphasis on Women, Newborns, Children and Adolescents

We the undersigned pledge our commitment to realizing the targets which we have set in this document for the improved access and equity for quality of health care for the mothers and children of Zimbabwe.

The HDF comes at a time when a good baseline has been created by the Health Transition Fund and the Integrated Support Programme among the other Programmes which have worked to reduce the maternal mortality ratio (MMR) and the rate (IMR). These achievements though significant, have not yet reached the targets which the country requires to be called a healthy nation and as such the Health Development Fund has new targets which are in line with the National Health Strategy 2016- 2020. The target for MMR by 2020 is set at 350 maternal deaths for every 100,000 live births. This is ambitious, but we are hopeful that should the resources be made available this can be achieved in the coming five years. In addition to this, Sexual and Reproductive Health an important and critical component of the National Health Strategy is included in the HDF. It is targeted to reduce the unmet need for family planning to 6.5% by the end of 2020 as the main tracer indicator for the efforts that will be put into Sexual Reproductive Health Rights in Zimbabwe.

Brigadier General (Dr) G. Gwinji Annabel Gerry Permanent Secretary for Health and Child Care DFID Head of Office in Zimbabwe HDF Chair HDF Co-Chair

R. Hossaini Cheich Tidiane Cisse UNICEF Country Representative UNFPA Country Representative HDF Fund Administrator Participating UN Agency

i Contents

Summary of Contribution ...... ii

Abbreviations and Acronyms ...... v

Executive Summary ...... ix

1 Background ...... 1

2 Situation Overview of Reproductive, Maternal, Newborn and Child Health ...... 7

3 Health Development Fund - Overall Goal and Purpose ...... 20

4 Thematic Areas - Detailed Description ...... 22

5 Coordination and Cross Cutting Issues ...... 33

6 Feasibility and Risks ...... 35

7 Monitoring, Evaluation and Reporting ...... 37

8 Programme Management ...... 40

9 Programme Co-ordination ...... 46

10 Resourcing the Health Development Fund ...... 48

Annex 1: MIMS 2009, DHS 2010 and MICS 2014 Indicator Trends and HDF Baselines ...... 52

ii Summary of Contribution

Country Zimbabwe

Title of Proposal Health Development Fund (2016-2020)

Proposed Donors Governments of Canada, Ireland, Norway, Sweden, United (currently involved in the Kingdom, European Union, and GAVI. (It is envisaged that HTF) additional donors will also become involved).

Project Duration 5 years - 2016 to 2020

Funds Required US$ 681.91 Million (total amount for 5 years )

Objective Aim: To support the Ministry of Health and Child Care in the context of the 2016-2020 National Health Sector Strategy to achieve its goals of improving the quality of life of its citizens, through guaranteeing every Zimbabwean access to comprehensive and effective health services. Goal: To contribute to reducing maternal mortality (by 50%) from 614 and under-5 mortality (by 50%) from 75, by ensuring equitable access to quality health services for women and children by 2020; and to contribute to the reduction of the unmet need for family planning to 6.5%, halving the prevalence of stunting in children under-5 from 28% and eliminating MTCT by 2020, combating HIV and AIDS, and other prevalent diseases Purpose: To continue to consolidate and improve on gains made in maternal, new born child and adolescent (young people) health by strengthening health systems and scaling up the implementation of high impact Reproductive Maternal New born Child and Adolescent Health (RMNCH-A); and nutrition interventions through support to the health sector.

Thematic Area 1, Maternal, Newborn and Child Health and Expected Results Nutrition l National coverage of focused ANC (4 visits) increased to 80% by 2020 l National skilled birth attendance rate increased to 85 % by 2020

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Expected Results l Access to comprehensive emergency obstetric and newborn care increased to 85 % by 2020 l 90% provinces and districts conducting quarterly maternal death reviews by 2020 l National coverage of postnatal care (at least 2 visits in the first week after delivery) increased to 85% by 2020 l The proportion of sick newborns treated appropriately for sepsis according to national guidelines increased to 60% by 2020 l The proportion of sick children under-5 treated appropriately for common childhood illnesses (pneumonia, diarrhoea and malaria) increased to 45%, 30% and 90% respectively by 2020 l National full immunization coverage increased to 75% by 2020 National coverage of exclusive breastfeeding rate increased to Expected Results l 60% by 2020 l The national coverage rate of timely and appropriate comple - mentary feeding increased to 70% by 2020 l The national coverage rate of twice a year Vitamin A Geographic Focus supplementation for children 6 -59 months of age increased Area to 90% by 2020 National coverage for Antiretroviral treatment for children Focus population l 0 – 14 years increased to 91% by 2020 Strategic Partners

Thematic Area 2, Sexual Reproductive Health Rights

l Percentage of users of long acting methods of contraception increased from 1% to 5% l Unmet need for family planning among females aged 15-19 re - duced from 17% to 8.5% l Unmet need (Limiting) for family planning (age 40-44) reduced from 12.9% to 6% l Percentage of sexually active HIV positive women who use a modern method of contraception (Contraceptive Prevalence Rate, CPR) increased from 63.8% to 68% l Percentage of women aged 15-49 accessing cervical cancer screening services increased from 9% to 35%. l Percentage of facilities offering youth friendly services that meet national standards increased from 6% to 25% l Percentage of young people among users of minimum pack - age of SRH services increased (to be defined and baselines to be determined) l Adolescent fertility rate reduced from 120 to 115 per 1000 l Percentage of young women 15-19 who have ever experi - enced physical violence decreased from 23% to 15%

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Expected Results l Percentage of women and girls who report having used services after being abused increased from 15% to 20% (police) and 2.2% to 10% (Social service) l 400 fistula repaired in supported sites by 2020.

Thematic area 3, Medical Products, Vaccines and Technologies (Medicines and Commodities) l Availability of essential medicines including contraceptives (the selected package) and health commodities is maintained at 80% in all rural health facilities across Zimbabwe by 2020 l Availability of vaccines (antigens), vaccine supplies and cold chain equipment maintained at 90% in all health facilities across Zimbabwe by 2020 l Percentage of rural health facilities with a stock out in the last three months on the essential medicines.

Thematic area 4, Human Resources for Health l 95% of Health facilities and health management offices are staffed with the minimum standard required and qualified pro - fessionals by 2020

Thematic area 5, Health Financing l Result Based Health Financing implemented in all rural health facilities of Zimbabwe by 2020

Thematic area 6, Health Policy, Planning, M & E and Coordination l 100% of rural health centres have a fully functional health centre committee by 2020 l Health system capacity in policy making, planning and financing developed across all health service delivery levels by 2020

Thematic area 7, Technical Support, Operations Research and Innovation l At least one operations research conducted on innovation on inter sectoral collaboration and building of synergies in RMNCH-A and SRHR in the country by 2020.

Geographic Focus Area National

Focus population Women, Children and Adolescents (in particular pregnant and lactating women and children under-5)

Strategic Partners Ministry of Health and Child Care, Funding Development Partners, UN agencies, Civil Society Organisations and other health development partners, Local Authorities and local leaders.

v Abbreviations and Acronyms

ANC Antenatal Care DHT District Health Team

ARI Acute Respiratory Infection DHMT District Health Management Team

ASRH Adolescent Sexual Reproductive Health DPs Development Partners

BEmONC Basic Emergency Obstetric and Newborn DPT Diphtheria Pertussis Tetanus (combined Care vaccine)

BCG Bacille Calmette Guerin (vaccine against DPPME Department of Policy, Planning, Monitoring ) and Evaluation (of the MoHCC)

CCORE Collaborating Centre for Operational EBF Exclusive Breast Feeding Research and Evaluation EC European Commission CDC Centre for Disease Control EmONC Emergency Obstetric and Newborn Care CEmONC Comprehensive Emergency Obstetric and Newborn Care EPI Expanded Programme on Immunization

CHERG Child Health Epidemiological Review Group EU European Union

CIDA Canadian International Development FAFA Financial and Administrative Framework Agency (now DFATM-Canada) Agreement

CMAM Community based management of Acute FP Family Planning Malnutrition FANC Focused Antenatal Care CS Caesarean Section GAVI Global Alliance on Vaccines and CSOs Civil Society Organizations Immunisation

CVS Central Vaccine Stores GBV Gender Based Violence

DFATM Department of Foreign Affairs, Trade and GDP Gross Domestic Product Development (of Canada) GFATM Global Fund to Fight AIDS, Tuberculosis DFID Department for International Development and Malaria (also referred to as Global (UK ) Fund)

DHEs District Health Executives GPRHCS Global Programme on Reproductive Health Commodities and Security DHIS District Health Information System GOZ Government of Zimbabwe DHIS 2.0 District Health Information Software version 2.0 H4+ UN Partnership for women and child health (UNAID, UNFPA UNICEF, WHO and WB) DHS Demographic and Health Survey

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HDF Health Development Fund MIMS Multiple Indicator Monitoring Survey

HCC Health Center Committee MLM Mid-Level Management (training for immunization) HIS Health Information System MNCH Maternal and neo natal and child Health HIV Human-Immuno Deficiency Virus MODO Ministry of Health and Development HMIS Health Management and Information Organizations (planning and review System meetings)

HRH Human Resource for Health MoF Ministry of Finance

HSB Health Services Board MoHCC Ministry of Health and Child Care

HTF Health Transition Fund MPMS Maternal and Perinatal Mortality Study

ICCM Integrated Community Case Management MTCT Mother to Child (of HIV) (of common childhood illnesses) MTR Mid-Term Review ICF ICF International MWH Maternity Waiting Home IFA and Folic Acid NCDs None Communicable Diseases IGMME Interagency Group on Maternal Mortality Estimates NIHFA National Integrated Health facility Assessment IMNCI Integrated Management of Newborn and Childhood Illnesses NHS National Health Strategy

IPV Inactivated Polio Vaccine OCP Oral Contraceptive Pills

ISP Integrated Support Programme OF Obstetric fistula

ITN Insecticide-Treated Net OPV Oral Polio Vaccine

IUCD Intrauterine Contraceptive Device ORS Oral Rehydration Salts

IYCF Infant and Young Child Feeding ORT Oral Rehydration Therapy (Treatment)

JRM Joint Review Mission PCNs Primary Care Nurses

LAM Long Acting Method PCV Polio-Containing Vaccine

LEEP Loop Electrosurgical Excision Procedure PEPFAR U.S. Presidential Emergency Funds for AIDS Relief LSTM & H Liverpool School of Tropical Medicine and Hygiene PHC Primary Health Care

M&E Monitoring and Evaluation PHEs Provincial Health Executives

MDGs Millennium Development Goals PHT Provincial Health Team

MICS Multiple Indicator Cluster Survey PMDs Provincial Medical Directors

MMR Maternal Mortality Ratio PMI U.S. Presidential Malaria Initiative

vii Health Development Fund Programme Document 2015

PNC Postnatal Care TFR Total Fertility Rate

PPPs Public-Private Partnerships UNAIDS United Nations Joint Programme on HIV and AIDS PPPME Policy, Planning, Programming, Monitoring and Evaluation (Directorate of the MoHCC) UNDP United Nations Development Programme

QoC Quality of Care UNFPA United Nations Population Fund

RBF Results-Based Financing UNICEF United Nations Children's Fund

RTIs Reproductive Tract Infections USAID Agency for International Development RBM Results-Based Management VHWs Village Health Workers RED Reaching Every District (with immunisation services) VIAC Visual Inspection with Acetic Acid and Cervicography RHCs Rural Health Centres VMAHS Vital Medicines Availability and Health RMNCH-A Reproductive Maternal New born Child and Services Survey Adolescent Health VMMC Voluntary Medical Male Circumcision RTIs Reproductive Tract Infections WASH Water, Sanitation and Hygiene SAM Severe Acute Malnutrition WHO World Health Organization SIDA Swedish International Development Agency WISN Workload Indicator of Staffing Needs SRH Sexual & Reproductive Health YFHS Youth Friendly Health Services SRHR Sexual and Reproductive Health and Rights ZDHS Zimbabwe Demographic and Health Survey TB Tuberculosis ZimAsset Zimbabwe Agenda for Sustainable Socio- TBA Traditional Birth Attendant Economic Transformation

viii Executive Summary

This programme document titled, 'Health Development Fund 2016 to 2020, is intended to be financed by the current Health Transition Fund donors, namely the Governments of Canada, Ireland, Norway, Sweden, United Kingdom; the European Union and other prospective donors. This programme takes forward some of the work currently supported through the Health Transition Fund (HTF), H4+ Programme, EU MDG initiative, Integrated Support Programme (ISP), and Global Programme on Reproductive Health Commodities & Security (GPRHCS) These funding mechanisms were established to support and revitalize Zimbabwe’s health sector which was near collapse as a result of the economic challenges experienced in the country during the period 2008/9. The proposed Health Development Fund (HDF) aims to continue consolidating and improving on gains that Zimbabwe has made in reproductive, maternal, new born and adolescent health and nutrition. It aims at further strengthening the health system and scaling up the implementation of high impact reproductive, maternal, new born, child and adolescent (young people) health and nutrition. The Ministry of Health and Child Care sees this document a vehicle to further strengthen the health system especially for the maternal mortality ratio and infant mortality rate reduction. The proposed programme is drawn from the National Health Sector Strategy and will continue to be implemented under the leadership of the Ministry of Health and Child Care (MoHCC) with all partners contributing to one plan, one coordinating mechanism and one monitoring framework. The 2016 -2020 National Health Strategy will be the main guiding document for all the interventions supported under the HDF.

During the 1980s and the 1990s, a highly effective health system was in place in Zimbabwe. Key characteristics were: Efficacy of organizational structure based on national governance, provincial leadership, and district management of the health system; adequate public expenditure on health (in excess of US$40 per capita); public/community support for health interventions by a well-educated population; well prepared and supervised health professional staff; and functioning information and logistical support systems.

The economic challenges of the past decade progressively undermined this system and contributed to an eventual rapid deterioration in maternal, new born, child and adolescent health indicators thus putting Zimbabwe off-track in achievement of the Millennium Development Goals (MDGs). The period also saw rapid spread of HIV and significant challenges with availability of Anti-Retroviral Therapy, with increased HIV/AIDS mortality and morbidity amongst mothers and children and reduction in life expectancy of the general adult population.

ix Health Development Fund Programme Document 2015

analyzed the various bottlenecks that impeded health care provision. The specific findings established that

ZIMBABWE human resources for health and essential health commodities were the major supply side bottlenecks. The HTF was therefore set up as a national programme Health with a focus on the primary health care level. Around the Transition same time, several other initiatives, such as H4+, ISP, MWH and GPRHCS also came forward to support Fund MoHCC on Reproductive Maternal Neonatal Child and Adolescent Health (RMNCH-A). The analysis at the time A Multi-donor Pooled did show that among the priority areas for the Transition Fund for Health Government of Zimbabwe, maternal and child health were the most underfunded programmes in the health in Zimbabwe sector.

Supporting the In the period 2012 – 2015, the following 4 core thematic National Health Strategy areas have been supported through the HTF to improve access to quality health care mechanism. in Zimbabwe l Maternal, newborn and child health and nutrition December 2011 (scaling up the implementation of high impact Maternal Newborn and Child Health (RMNCH-A) and Nutrition interventions) l Medical products, vaccines and technologies (Medicines, blood and commodities) l Human resources for health (Health worker management, training and retention) The Health Transition Fund (HTF) among other funding modalities was set up in 2011, in a highly polarized l Health policy, planning and finance (Health political environment. At that time, development Services Fund and research) partners were willing to come together to support the In addition, other implementing partners supported health sector based on the findings of the Health Sector Integration of sexual reproductive health services Investment Case which analyzed the various (Family Planning, HIV, GBV and Cervical Cancer), Health bottlenecks that impeded health care provision. The Information System and M&E, Demand and Community specific findings established that human resources for Participation, and Communication and Advocacy. health and essential health commodities were the major supply side bottlenecks. The HTF was therefore set up In terms of achievement the HTF together with other as a national programme with a focus on the primary initiatives have contributed significantly to the removal health care level. Around the same time, several other of critical health system bottlenecks and thus initiatives, such as H4+, ISP, MWH and GPRHCS also strengthening the Health System, mainly through:: came forward to support MoHCC on Reproductive l Human Resource for Health resulting in key Maternal Neonatal Child and Adolescent Health personnel now being retained in the system (RMNCH-A). The analysis at the time did show that Ensuring availability of essential medicines, among the priority areas for the Government of l vaccines and commodities Zimbabwe, maternal and child health were the most underfunded programmes in the health sector. l Strengthening the M&E system, including strengthening of supervision and monitoring findings of the Health Sector Investment Case which efforts

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l Covering the routine and running costs of primary are seeking to mobilise partner support. Furthermore, it health centres in the rural areas. This helped to has been proposed that GAVI funding support for the reduce user fees for pregnant women and EPI programme will subsequently be channelled through children less than five years of age in 94% of the HDF. Primary Health Care (PHC) facilities. The key guiding principles of this programme are as l Promotion of integration of sexual reproductive follows: health and all other services to achieve efficiency of service delivery Firstly, it is emphasized that without continued economic recovery and political stability, any gains There are palpable signs that the health system is made in the health sector will remain fragile. Further to recovering, resulting in increased coverage of key this, if government is to achieve its objectives for the RMNCH-A high impact interventions. For the first time health of the people of Zimbabwe, the proportion of after almost twenty years of continuous deterioration public expenditure allocated to health needs to be recent data (MICS 2014) shows that, Zimbabwe has increased and other innovative ways of financing the managed to bend the curves of the alarmingly high sector in a sustainable manner need to be explored. In maternal and under 5 mortality. addition, more effort is needed in scaling up the health However, in order to push the maternal and child financing initiative that the MoHCC has started. With mortality curve further down there is need to focus on this in mind the change of name from Health Transition improving the quality and equity of health services Fund (HTF) to Health Development Fund (HDF) reflects a provided to mothers, children and adolescents while still progressive shift from support for recurrent costs continuing and increasing the momentum of the current (increasingly funded by government) to a combination of interventions. Nutrition is a critical component for necessary recurrent support and health systems pregnant women and children and it will be focused on investments that make funds from all sources more in the HDF. In addition to maintaining the coverage effective. achieved in some areas, special attention to voluntary Secondly, the cohesion and coherence achieved Family Planning (FP) programme, Youth Friendly Health through the Ministry of Health and Child Care leadership Services (YFHS) and Sexual and Reproductive (SRH) of the HTF needs to be maintained, and where possible and HIV service integration is necessary. Targeted extended across the whole health sector interventions. approach to reach specific vulnerable populations such However, the leadership, coordination and as newborns, adolescents and people living in hard to accountability arrangements need to be strengthened at reach communities, including those with particular the provincial level and below, through the full religious and socio-cultural leanings with quality restoration of effective Provincial Health Team (PHT) and services and correct information can further accelerate District Health Team (DHT) arrangements. It is noted that the achievement. This means that the health system strengthening of management at these decentralized building blocks which are crucial for the health system levels will allow for increased delegation of to be fully functional, and which have been supported responsibilities from the national level. by the HTF and other initiatives should continue to be supported until and unless secure and alternative Thirdly, a motivated workforce will provide the basis for funding and programming mechanisms are put in place. continued availability of health care services. In order to restore services, all health workers are receiving a Therefore, the financing partners of the HTF, H4+, MWH, retention allowance added to their salaries while staff on and ISP, UNICEF and UNFPA agreed to collaborate “critical posts” receive additional payments under the leadership of the Ministry of Health and Child supplementing their salaries hence enabling them to Care on a further phase of support to the people of stay in post and arresting the hemorrhage of trained Zimbabwe through a “Health Development Fund”, and

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professionals from the health system especially in rural rural health facility. Should resources permit, this can areas. In addition, the Results Based Financing (RBF) be scaled upwards to cover the district hospitals. schemes provide bonus payments based on improved District Hospitals and provincial hospitals will continue performance of health facilities. These payments have to receive input financing through Health Services Fund been crucial in retaining skilled health staff and remain support. highly justified. However, it is important that these Seventh, to increase effectiveness of resource interventions are eventually harmonized into a single utilization, support will be provided to a flexible fund to salary system in the public sector. In consultation with improve key aspects of health service delivery, focused the Ministry of Health and Child Care, a target date on reducing mortality and morbidity in the “hardest to (such as January 2018) could be proposed for reach” client groups and geographical areas. This fund transitioning to this system aiming to have full will provide technical assistance, support innovations government funding by the agreed target date. Existing and advance their implementation and evaluation. The service-specific incentives such as VMMC will be fund will be available to government and non- evaluated and integrated into the current human government organizations and may also be useful in resource support in a coordinated manner. schemes that will help to maximize the impact of health Fourth, a professional and skilled workforce will be a services funded through other initiatives (e.g. HIV/AIDS; key assurance that quality of services will be improved. TB; Water and Sanitation projects; etc.). Investment will be made in continuing to support: Eighth, the programme will capitalize on the gains of the training of staff in key shortage areas, clinical ISP programme to further strengthen the integration of mentorship and supportive supervision, and continued Sexual Reproductive Health information and services, professional development. . However, a review of the especially those which directly impact on maternal approach to post-basic in-service training is essential at national level. This should result in a nationally mortality reduction, such as Family Planning. Focus will coordinated, provincially implemented training be given to the most vulnerable groups of the programme covering all appropriate competencies. It population including adolescents, youth and key should seek to ensure appropriate numbers of populations and strive towards enhanced partnership adequately trained staff at all levels, while minimizing with social sector programmes, in areas such as duplication and time away from station. education and gender. For Nutrition, lessons learned from the current pilot inter-sectoral programme in four Fifth, support will continue to be given to a districts will be built on. pharmaceutical supply system that includes selected commodities and contraceptives (free and fully funded) Contributing to the National efforts, the HDF will support to the client for specific groups (among them mothers the Ministry of Health and Child Care to achieve its and children under five including malnourished children) goals and strategies that aim at improving the quality of and low cost and good quality commodities for other life of Zimbabweans, attained though guaranteeing clients made available on a timely basis through a “pull” every Zimbabwean access to comprehensive and system. effective health services.

Sixth, as the current HTF provided funds to Rural Health The Goal of the HDF will be To contribute to reducing Centres through the RBF facility, patients referred from maternal mortality (by 50%) and under-5 mortality (by this level to the district and provincial level should have 50%), by ensuring equitable access to quality health a voucher system to allow them to be attended to. The services for women and children by 2020; and to voucher system design will be incorporated into pillar 7. contribute to the reduction of the unmet need for family Ideally, although RBF should be implemented at district planning to 6.5%, halving the prevalence of stunting in level, due to limited resources, the focus will be at the children under-5 and eliminating MTCT by 2020,

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combating HIV and AIDS, Malaria and other prevalent l Thematic Area 4:Human Resources for Health diseases. (including Health Worker Management, Training and Retention) The Purpose is to continue to consolidate and improve on gains made in maternal, new born and child health l Thematic Area 5: Health Financing (Result-Based by strengthening health systems and scaling up the Financing or RBF) implementation of high impact Reproductive Maternal l Thematic Area 6 : Health Policy, Planning, M&E Newborn Child and Adolescent Health (RMNCH-A) and and Coordination nutrition interventions through support to the health sector. l Thematic Area 7: Technical Support and Innovation The HDF will provide support across the full range of The governance of the pooled fund will be through the health services whilst continuing to provide key support HDF Steering Committee. This will be led by the Ministry to RMNCH-A and nutrition services, as well as of Health and Child Care with representation from all key enhancing equity in health care availability, through stakeholders (whether pool funders or not) and co- targeting newborns, adolescents, hard to reach chaired by the funding partners who rotate on an annual communities and specific sections of society either basis. The Steering Committee will have representation poorly reached or unreached by health system. The from funding partners, Civil Society, Private sector, focus will be on consolidating gains made at the primary United Nations Agencies and the Ministry of Finance. care level and in district hospitals, with a move to The Ministry of Health and Child Care in consultation selected support at provincial level. Development with stakeholders will determine the best means of partners will be encouraged to allocate the majority of achieving strong coordination and efficiency, and will their health sector support to a pooled fund under the build on the success of the Joint Review Mission (JRM) guidance of the Ministry of Health and Child Care. and other key accountability and coordinating Within this context the following seven thematic areas mechanisms. which provide continuity and build on existing Table 1 overleaf illustrates the resource requirements for foundations are proposed. the period 2016 to 2020. The budget is based on resources expected to sustain momentum and which l Thematic Area 1: Maternal, Newborn, Child Health and Nutrition would provide a realistic chance of achieving the new health targets in the draft National Health Strategy 2016 l Thematic Area 2: Sexual and Reproductive Health to 2020 which is still under preparation. In the event and Rights (SRHR) (including Adolescents) that that only a portion of these funds is mobilized, it will l Thematic Area 3: Medical Products, Vaccines and be important to pursue allocating resources in all the Technologies (Medicines and Commodities) seven thematic areas.

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Table 1: HDF resource requirements for seven thematic areas (US$ in Millions)

Thematic Area 2016 2017 2018 2019 2020 Total

HDF PILLARS

1. RMNCH-A Service Delivery 39.41 7.97 8.57 8.45 7.80 6.62

2. SRHR 185.00 37.00 54.00 51.00 22.00 21.00 3. Medicines, Commodities (including Nutrition commodities) and 208.74 39.09 40.57 41.79 43.02 44.27 Technologies

4. Human Resources for Health 70.23 14.53 13.28 11.92 14.11 16.39

5. Finance (RBF) 56.90 11.07 11.32 11.42 11.51 11.58 6. Policy, Planning, M&E and 18.79 Coordination 4.97 4.87 3.99 3.02 1.94

7. Technical Support and Innovation 23.23 4.50 5.12 4.74 4.37 4.50

Sub-Total for Thematic areas 602.30 119.13 137.73 133.31 105.83 106.30

Programme Management Costs 35.00 7.00 7.00 7.00 7.00 7.00

Total Programmable Budget 637.30 126.13 144.73 140.31 112.83 113.30

Recovery Costs 44.61 8.83 10.13 9.82 7.90 7.93

Total HDF Budget 134.96 154.86 150.13 120.73 121.23 681.91

1 a) Pediatric HIV and AIDS* 2.6 3.5 3.1 3.0 2.7 14.9

Notes

The total budget for HDF is USD681.91 Million

The recovery costs and programme management costs include those for both UNICEF and UNFPA

A detailed budget with the split between UNICEF and UNFPA is in Annex 2

*This budget is not funded through HDF and thus not included in the total figures

xiv CHAPTER 1 Background

In the 1980s and 1990s, the Zimbabwe Health System was arguably one of the best on the African continent. However, economic challenges of the past decade progressively undermined the health system and contributed to an eventual rapid deterioration in maternal, new born, and child health indicators. The expenditure on health per capita deteriorated significantly from US$42 in 1991 (which was the highest in sub-Saharan Africa) to just under US$6 in 2009.

As a consequence, major challenges were faced in the health sector including; loss of professional staff, dysfunctional health infrastructure, lack of drugs and equipment, outdated policies and procedures and facilities being unable to cover their running costs. By 2008/ 2009, the health system was in a state of near collapse, manifested in emerging disease , and a huge outbreak in 2008 which the system was unable to contain, resulting in the loss of 4,000 lives. A measles outbreak in 2009 claimed the lives of 1,600 young children. The impact of these crises was a rise in maternal mortality from 390/100,000 live births recorded in 1990 to 960/100,000 live births in 2010 (ZDHS-2010). Under five mortality also increased from 74/1,000 live births to 94/1,000 live births (MIMS- 2009).

At the same time the rapid spread and lack of widely available treatment for HIV and AIDS increased mortality and morbidity amongst mothers and children and reduced the life expectancy of the adult population. The HIV prevalence increased steadily through the 90s to an estimated peak of 29% in 1997 and life expectancy dropped from to 60.1 years in 1990 to just 47 in 2000. Non-communicable disease prevalence also rose steadily with an estimated 1,855 women were being diagnosed with cervical cancer and 1,286 dying annually from the disease (WHO/HPV Centre 2010 estimates). Amongst the poorest, all of this was further exacerbated by poor nutrition as Zimbabwe continued to face nutritional challenges with an estimated 35% of all children under the age of 5 experiencing stunting in 2010 and more recent estimates at 28% (MICS, 2014). The weakened health system is still no well positioned to cope with the growth in non- communicable diseases.

In the period from 2009 to 2014, the beginnings of recovery has been observed and the key elements contributing to this recovery have been: l Clarity of overall Government and Ministry strategies; l Development Partner support in addressing key health services delivery bottlenecks mainly through harmonized aid modalities (pooled funding mechanisms);

1 Health Development Fund Programme Document 2015

l Strong institutional framework, experience, sector. The HTF was a comprehensive programme that capacity and institutional memory still in place aimed to ‘build back better’ the health system by and evidence of strong resilience of systems; primarily addressing constraints in human resources, commodities, monitoring and evaluation, and financing l Available and motivated, professional staff; while also addressing inequitable access especially l Focus on essential, high impact interventions made worse by user fees. While the fund was based on the key health system pillars; transitional in nature, it was designed to enhance continuity of critical health system functions under all Good health seeking behavior in the population; l contingencies, including humanitarian situations. l Economic recovery. 1

The key Development Partners supporting the Government of Zimbabwe in the health sector are UK DFID, European Union, CIDA, Irish Aid, SIDA, Norwegian Government (focusing on women and children), the Global Fund; partnership of the United Nations organizations, USAID/PEPFAR (focusing on HIV/AIDS, TB and Malaria treatment) and the World Bank (focusing on Results Based Financing). All these partners are providing coordinated support through different programmatic funds such as the Health Transition Fund (HTF) which is managed by UNICEF, the ISP (pillar 2), H4+, MWH, and GPRHCS, which are managed by UNFPA. All different programmatic funds are aligned to the National and Sectoral Policies and are led by the Ministry of Health & Child Care.

The Health Transition Fund (HTF) was set up in 2011 by The HTF was focused on four core thematic areas: a coordinated effort of the Ministry of Health and Child Maternal, newborn and child health and nutrition Care and key health development partners. This was in l (scaling up the implementation of high impact response to the challenges facing the health sector. The RMNCH-A interventions such as EmNOC, IMNCI, development partners were willing to support the health EPI etc.) sector in a coordinated manner to address the system wide challenges at the time. The analysis that led to the l Medical products, vaccines and technologies development of the Health Investment Case was used (provision and distribution of vital medicines, to identify the priorities within RMNCH-A area. It was blood and commodities) established that human resources for health and l Human resources for health (Health worker essential health commodities were the major management, training and retention) bottlenecks and that maternal and child health interventions were the most underfunded areas in the l Health policy, planning and finance (Health Services Fund and research).

The HTF is a pooled fund in support of the

1 implementation of the National Health Strategy of the Between 2009 and 2012 GDP growth has averaged 10.5% http://www.imf.org/external/pubs/ft/scr/2014/cr14202.pdf , and this has Government of Zimbabwe and managed by UNICEF enabled more expenditure by government and households to go towards with technical and financial contributors being; DFID, health EU, CIDA, Irish Aid, Norwegian Government, and Swedish Government. The Ministry of Health and Child

2 Health Development Fund Programme Document 2015

Care (MoHCC) is the implementing agency and in are stocked with essential medicines at any given time consultation with the different departments and (Vital Medicines Availability and Health Services Survey subnational management bodies, takes the lead in or VMAHSS). Through Results Based Financing, the identifying priority areas of the health system that need HTF provides a monthly grant to 1,500 health facilities to be supported through the HTF. The HTF Steering to cover their running costs. User fees were removed in Committee is responsible for the oversight and decision. 94% of the rural primary health centers and 83% of the urban health facilities which are now providing services The support to the National Health Strategy also free of charge to pregnant women and children aged included the following interventions managed by five years of age and below. UNFPA: The Integrated Support Programme (ISP) which started in 2012 with an aim to strengthen integrated The HTF has contributed significantly to removing the SRH information and services, such as family planning, critical health system bottlenecks mainly in the areas of: cervical cancer, Gender Based Violence and HIV Human Resource for Health resulting in key through funding support of DFID, SIDA and Irish Aid. l personnel now being retained in the system The H4+ also initiated in 2012 as a coordinated UN effort in six districts to strengthen maternal health l Ensuring availability of essential drugs, vaccines through a focus on health system strengthening funded and commodities by SIDA and CIDA. The MDG initiative to revitalize the l Strengthening the M&E system with supervision Maternity Waiting Homes (MWHs) to address the and monitoring efforts being put in place or second delays throughout the country through EU strengthened support, and the Global Programme on Reproductive Health Commoditi es and Security (GPRHCS) which l Covering the routine and running costs of primary health centres, which helped to remove user fees provides strategic support to strengthen commodity for pregnant women and children under five year. 2 security for FP and Maternal Health and to enhance choice and quality of FP.

In addition to the above, other key Development KEY ACTIVITIES AND Partners funding the health sector include: ACHIEVEMENTS ATTAINED USAID/PEPFAR (focused on HIV/AIDS, TB and Malaria THROUGH OTHER MAJOR treatment), the Global Fund, GAVI, PMI and other INITIATIVES multilateral and bilateral funding modalities. The HTF H4+: It is a joint UN initiative with UNICEF, WHO, UN due to its national implementation, focusing on primary Women and UNAIDs coordinated by UNFPA. Since health care facilities and systems strengthening has inception in 2011, H4+ has strengthened RMNCH-A been instrumental in catalyzing the overall effort in programme delivery in the country by contributing to the resuscitating the health sector. development and revision of several RMNCH-A guidelines, and strengthening health systems by KEY ACTIVITIES AND enhancing capacity, ensuring availability of essential ACHIEVEMENTS ATTAINED medicines and supplies, providing infrastructural THROUGH THE HTF support, reinforcing community and firming up monitoring and supervision mechanisms. Through the The HTF activities include the training and deployment programme, 1) 48 health facilities were supported to of more than 2,500 midwives and the provision of critical post allowances which has helped to increase the number of doctors at the district hospital level from 70 in 2011 to 139 in 2014. Today, each district hospital 2 has at least one doctor who can perform cesarean Vital Medicines Availability and Health Services Availability Services section. More than 85% of primary health care facilities Survey, Round 19 (Jan-Mar 2014).

3 Health Development Fund Programme Document 2015

offer EmONC services in 6 H4+ supported districts exposures by girls aged 10-19years through Sista2sista including provision of EmONC equipment, supply and clubs, 64,565 young people 16-24years accessed FP at essential RH medicines. 2) Key national RMNCH-A supported sites and 80,000 person exposures (young policies, guidelines and protocols were revised or people 10-24years) to SRH information, including developed, such as PNC guidelines, Revised WHO through social media. 5) Supported 6040 GBV National HIV guidelines (Option B+), National Nutritional survivors to access and receive services at shelters and Strategy, National Infant and Young Child feeding one stop centres, 5,856 community leaders, health Strategy, Emergency Triage Assessment and Treatment personnel, police officers, court officers were trained on (ETAT) guidelines, and clinical mentorship guidelines, GBV management. etc. 3) Extensive health care providers trainings were GPRHCS: Managed by UNFPA, the Global Programme supported, including 317 Health workers trained on on Reproductive Health Commodities and Security BEmONC; 632 on IMNCI; 371 on IYCF; 589 on Pediatric (GPRHCS) programme contributes to strengthening ART / Option B+; and 371 on Growth Monitoring. 4) national capacity for coordinating the joint efforts in the Maternal Death Review meetings were conducted in all country for achieving FP2020 commitments made by supported provinces. 5) Contraceptives were provided the government of Zimbabwe and contributes to to 5,542 new young girls in Youth Friendly Health commodity security of essential reproductive medicines Facilities in Hurungwe and 6). 121 community groups or and supplies. It has supported national efforts on rural committees were established on RMNCH- strengthening contraceptive method mix, especially long A/HIV/IYCF issues and 114,316 persons exposed to acting methods by building capacity of 700 service community dialogues on RMNCH-A/HIV issues. providers and strengthening policy environment for MWH: UNFPA has supported MOHCC to revitalise 103 integrated FP information and services. The government Maternity Waiting Homes (MWHs) across the country, was supported to develop a national family planning procured 63 ambulances for all the district hospitals and strategy (2015-2020). The following RH commodities equipment and nutritional supplies for the MWHs. To and drugs have been procured under the GPRHCS: date, about 90,000 women have been admitted into the implants, emergency contraceptives, syphilis test kits, MWHs and 600 health workers have been trained on oxytocin, magnesium sulphate and calcium gluconate. provision of EmONC services. The districts and provinces have also been supported in conducting maternal death review meetings. IEC and promotional INDICATIONS OF IMPROVEMENT materials for MWHs have also been developed. There are palpable signs that the health system is ISP: Led by UNFPA (Pillar 2), the Integrated Support recovering, resulting in increased coverage of key Programme (ISP) has contributed to the improvement of RMNCH –A high impact interventions (Multiple Indicator women and girl’s SRH through the provision of family Cluster Survey - MICS2014). For the first time after planning (FP) services, cervical cancer screening and twenty years of continuous incline, Zimbabwe has treatment, HIV prevention and GBV prevention and managed to bend the alarmingly high maternal mortality response. Key achievements of the ISP are: 1) curve as evidenced by the 2012 Census findings, the Supported MOHCC to setup 56 health facilities that are 2013 Inter Agency group for Maternal Mortality offering cervical cancer screening services using VIAC. Estimate and the 2014 Multiple Indicator Cluster Survey 94,000 women have been screened for cervical cancer (Fig 1). in the public health sector from 2012 to 2014. 2) 700 In 2010, the estimated annual maternal deaths were service providers trained and 258 health facilities 3,840. According to the MICS 2014, this figure has supported to offer FP services including implant come down to 2,456, using 400,000 as the total annual insertions. 3) 397,160 households were reached through live births. This implies that, within the last couple of home visits aimed at generating integrated and specific years, the country has managed to avert a total of 1,384 demand for SRH/HIV/GBV services with 434,937 maternal deaths annually. Similarly , in 2009, there were referrals made to various services. 4) 121,876 person around 37, 600 deaths of children less than five years of

4 Health Development Fund Programme Document 2015

outcomes necessitate the need for prevention of HIV 1200 among women and girls of reproductive age as a critical 1068 approach to reducing child mortality and improving 1000

s 960 maternal health. This will entail more comprehensive h t r i programming, better coordination and maximizing on b

e 800 v

i 740 efficiencies among all actors especially those l

695 0

0 615 addressing SRHR and HIV needs. It also means the 0 680 ,

0 600 0 525 four health system blocks that are crucial for making the 1 550 r

e 520 system fully functional and that have been supported p

470 400

R through the HTF should continue to be funded until and M

M unless alternative funding mechanisms are put in place. 200 It is further noted that the national macroeconomic situation remains uncertain, and the rate at which 0 government can increase its expenditure on health is 1990 1992 1994 1996 1998 20002002 2004 2006 2008 2010 2012 2013 2014 still limited and shows no sign of being able to pick up IGMME CENSUS SISTERHOOD METHOD in the foreseeable future. However, efforts will continue Figure 1: Maternal mortality trends to be made to advocate for better health sector allocations and disbursement from the national revenue Source: MICS, 2014 budget, but it is clear that continued partner support is essential for a further period of at least 5 years. Thus the 100 94 foundations have been laid, but the restoration of an 84 84 effective health care system is still far from complete, s 80

h 69 t 75 r i

b 75 and failure to consolidate and build upon progress e 80 v i l

0 made would lead to a risk of a rapid decline of this

0 55 55 0

1 40

r fragile system. Therefore health Development Partners e p

s 20 h agree on a further phase of support through a “Health t a e D 0 Development Fund” (HDF) and now seek to mobilise 1991 1994 1999 2001 2004 2006 2009 2012 financial resources around this programme following the Year one plan, one coordination mechanism and one DHS 2010-11 MICS 2009 MICS 2014 Census monitoring framework principle to enhance coordination Figure 2: U5 Mortality trends led by the MoHCC. It has been proposed that GAVI funding support for the EPI programme will Source: MICS, 2014 subsequently be channelled through the HDF. age annually but this figure has come down to 30,000 in The key guiding principles of this programme are as 2014 (MICS-2014). This again means the country is now follows: able to avert a total of 7,600 deaths of children less than First, First, it should be emphasized that without five years of age annually (figure 2). continued economic recovery and political stability, any However despite the declining maternal and child gains made in the health sector will be fragile. It is also mortality, the number of deaths remains unacceptably clear that if government is to achieve its objectives for high. In order to push the maternal and child mortality the health of the people, the proportion of public curve down further, there is a need to focus on expenditure allocated to health needs to be increased. improving the quality and equity of health services for With this in mind the change of name from Health mothers (including Family Planning), newborns and Transition Fund (HTF) to Health Development Fund adolescents. In addition, hard to reach communities, (HDF) reflects a progressive shift from support to religious and other socio-cultural objectors should be recurrent costs (increasingly funded by government) to a prioritized. The impact of HIV on reproductive health combination of necessary recurrent support and capital

5 Health Development Fund Programme Document 2015

investments to the sector that make funds from all system for selected commodities to specific client sources more effective. groups (free and fully funded for mothers and children under five) and low cost and good quality commodities Secondly, the cohesion and coherence achieved for other clients, made available on a timely basis through Ministry of Health and Child Care leadership of through a “pull” system. the HTF needs to be maintained and if possible extended across the whole health sector to achieve a Sixth , as the current HTF provided funds to RHCs and more integrated approach to Maternal Health and Child District Hospitals, and introduced a RBF approach for Health programmes and to further strengthen FP. The RHCs in 2014, building on the experience in 18 districts leadership, coordination and accountability supported by the World Bank, the next phase will need arrangements need to be strengthened at the provincial to ensure that an effective and efficient system is in level and below, through the full restoration of effective place. It is proposed that, whilst support will continue to Provincial Health Team (PHT) and District Health Team be given to other non-staff running costs at the primary (DHT) arrangements. Strengthening of management at and first referral levels through the RBF system, this these levels will allow for increased delegation from the subsidy should be focused on all the Primary Health national level. Care facilities. Special consideration will be made to hard to reach districts. Third, a well-motivated workforce will provide the basis for continued availability of health care services. In order Seventh , to increase effectiveness of resource to restore services all health staff have been provided utilization, support will be provided to a flexible fund to with a retention allowance added to their salary and improve key aspects of health service delivery focused additional payments have been made for selected on reducing mortality and morbidity in the “hardest to “critical positions” for ensuring effective and efficient reach” client groups and geographical areas. This fund RMNCH-A services delivery. In addition the RBF will support technical assistance and vanguard schemes are providing bonus payments based on implementation and evaluations. The fund will be performance. These payments have been crucial in available to government and non-government retaining health staff and remain highly justified. organizations and may also be useful in schemes that However, it is important that these interventions are will help to maximize the impact of health services eventually harmonized into a single salary system in the funded through other initiatives (e.g. HIV/AIDS; TB; public sector. It is proposed that a target date be set Water and sanitation projects; etc.). (such as 1st January 2018) for transition to this system Eighth , the programme will capitalize on the gains of the with the aim of full government funding by the agreed ISP programme to further strengthen the integration of target date. SRH information and services, especially those which Fourth, a professional and well skilled workforce will be directly impact on maternal mortality reduction, such as the main assurance that quality of services will be FP. Focus will be given to the most vulnerable groups of improved. Investment will be made in training of staff in the population including adolescent and youth and key shortage areas, clinical mentorship, supportive strive towards enhanced partnership with programme in supervision, and in continued professional development. other sectors, such as education and gender. A review of the approach to post-basic, in-service training is essential at national level. This should result in a nationally coordinated, provincially implemented Chapter 2 of this programme document describes the training programme covering all appropriate current position on maternal, newborn, and child health; competencies; it should seek to ensure appropriate the progress made; and the challenges still being faced. numbers of adequately trained staff at all levels, while minimizing duplication and time away from station.

Fifth, support will continue to be given to a pharmaceutical supply system that includes a “push”

6 CHAPTER 2 Situation Overview of Reproductive, Maternal, Newborn and Child Health

CHILD HEALTH

The 2014 MICS survey reports Under-five mortality rate at 75 deaths per 1,000 live births (compared to the 2009 MIMS rate of 94/1000 LB), and Infant mortality at 55/1000 (compared to the 2009 MIMS rate of 65 per 1000) 3 (see Table 2 below). Under 5 and IMR vary in by regions of the country, urban and rural areas, between boys and girls, and between the richer and the poorer. This is depicted in Figure 3, 4 and 5 below.

Table 2: Early Childhood Mortality Trends, Zimbabwe

ZDHS MICS % Indicator Description of Indicator 2010 2014 Decline Neonatal Mortality Probability of dying within Rate (NMR) per 1,000 31 29 6% the first month of life. live births Infant Mortality rate Probability of dying (IMR) per 1,000 live between birth and the first 57 55 4% births birthday. Under-Five Mortality Probability of dying rate (U5MR) per 1,000 between birth and the fifth 84 75 11% live births birthday. Indicator values refer to the five-year period before the survey.

Percentage 0 10 20 30 40 50 60 70 80 90 100

Harare 77 61

89 Masvingo 63

84 Under-five mortality rate Midlands 63 Infant mortality rate Matabeleland 85 South 67 Matabeleland 53 North 36 Mashonaland 74 West 58 Mashonaland 64 East 39 Mashonaland 91 Central 73 75 Manicaland 50 Bulawayo 48 37 Zimbabwe 75 55 3 For the MICS, infant and under-five Figure 3: Under five mortality and Infant Mortality by Province mortality rates were calculated from the mother’s birth history information using Source: MICS, 2014 the direct method of estimation.

7 Health Development Fund Programme Document 2015

90 90 80 Male 79 80 Urban 78 Female Rural 70 70 70 66 e e 60 59 60 g

g 56 a a t t 51

50 n n 50 50 e e c c r r e e 40 40 P P 30 30 20 20 10 10 0 0 Infant Under five Infant Under five mortality mortality mortality mortality rate rate rate rate Figure 4: Under-five and Infant Mortality Rates, Rural and Urban Areas, Male and Female Children, Zimbabwe, 2014

Source: MICS, 2014

diarrhoea (Child Health Epidemiological Review Group, 90 2013). Malnutrition is considered an underlying factor in 85 about 30% of these deaths. Figure 6 below depicts an 80 Poorest families

s Richest families approximation on how each cause contributes to overall h

t 70 r i under-five deaths in the country. b

e 60 58 v

i 55 l

0

0 50 48 0 , 1

r 40 e p 32 s 30

h 30 t 25 25 a 23 e

D 20

11 10

0 Neo natal Post Neo Infant Child Under 5 natal

Figure 5: Difference of mortality rates between richest and poorest families, Zimbabwe, 2011

Source: 2011 ZDHS (ZIMSTAT and ICF International, March 2012)

Causes of Child Deaths

According to different sources, the causes of death of children under the age of 5 in Zimbabwe are related to: neonatal deaths, AIDS, pneumonia, malaria and

8 Health Development Fund Programme Document 2015

Figure 6: Causes of Under-five Deaths in Zimbabwe, 2012

Source: WHO/CHERG 201 4 4

Neonatal deaths were treated with a combination of oral rehydration salts Most of the under five deaths happen during the (ORS) and , while 56.4% received ORT and neonatal period (within the first month of life of the continued feeding (ZIMSTAT and UNICEF, Aug 2014). child). According to the 2014 MICS, the neonatal mortality rate is 29/1000 live births, contributing to 39% Acute Respiratory Infection (ARI) of under five deaths. The Zimbabwe Health Acute Respiratory Infections accounted for 25.2% of all Management Information System for 2013 5 (Ministry of cases of patients seen in health institutions in Health and Child Care, 2013) indicated that there were Zimbabwe in 2012 6. The 2014 MICS shows that 5.3% of 8,601 neonatal deaths in Zimbabwe, the majority (78%) children under-five years of age had had ARI symptoms occurred in the first week of life, and based on the in the two weeks preceding the study, and of these, Perinatal Death Notification reports, 48% of the deaths almost 53% were treated at a health facility or by heath were due to complications of prematurity, 41% due to service provider. Among those treated, 34.3% received birth asphyxia and 11% due to neonatal sepsis. antibiotics. According to the 2014 MICS, 73.9% of households in Diarrhoea Zimbabwe use solid fuels as the primary source of Results from the 2014 MICS survey show that 15.5% of domestic energy to cook. Using WHO calculations to children under age 5 had suffered an episode of determine the burden of disease from Household Air diarrhoea in the two weeks preceding the survey. Pollution, the ARI risk for Children if there is 73.9% of Episodes of diarrhoea are more common in urban population using solid fuels, equates to 58% 7. settlements than rural areas. According to the Zimbabwe DHS 2011, 15% of the children in urban areas had diarrhoea in the two weeks preceding the 4 survey, in comparison with 12.5% in rural areas. Data available at Countdown to 2015 website: http://www.countdown2015RMNCH.org/country-profiles/zimbabwe MICS-2014 data shows that among those children that accessed on September 18, 2014. 5 presented with diarrhoea, 41.8% sought advice or Country administrative data system. treatment from a healthy facility or health service 6 2013 Health Bulletin, Q1. Data does not differentiate children from adults. provider. Only about 14% of the children with diarrhoea 7 http://www.who.int/phe/health_topics/outdoorair/databases/HAP_BoD_ methods_March2014.pdf?ua=1

9 Health Development Fund Programme Document 2015

Fever/Malaria 200 0 0

During the two weeks preceding the 2014 MICS survey, 0 1

27% of the children had experienced episodes of fever. r 155 e 153

p 150

136 Among these, 43.6% sought treatment in a health e

c 125 facility or provider, and 3% were treated with anti- n 116 e 112 109

d 99 malarial medicine. i 100 c 94 n i

a

In the non-endemic areas, malaria happens between the i r 58

a 49 months of February and May, and cases are more l a 50 M 25 concentrated in Mashonaland West and Mashonaland 21 Central, Masvingo and Manicaland Provinces. 0 According to UNDP report (May 2013), in total, 45 of 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Zimbabwe’s 61 districts have conditions that support Figure 7: Trend of Malaria Incidence, Zimbabwe moderate to high transmission of Malaria. Source: (UNDP, Malaria Indicator Survey, May 2013) The malaria incidences have been on a downward trend since 2011. See figure 8 below.

Figure 8: Paediatric ART Coverage by District

Source: 1994 ZDHS, 1999 ZDHS, 2005-06 ZDHS, 2010-11 ZDHS and 2014 MICS

8 By 2020, the cascading targets are to have at least 90 percent of all people living with HIV know their diagnosis; 90 percent of those people to be receiving antiretroviral treatment; and 90 percent of those on HIV treatment to have an undetectable viral load..

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Achieving the 90:90:90 8 targets in line with the Fast- highlights trends in stunting, underweight and wasting Track strategy to end the AIDS by 2030 since 1999. Furthermore, there is not much change in (UNAIDS) requires acceleration of the implementation of Global Hunger Index (GHI) for Zimbabwe, it was 20.5 in HIV prevention and treatment interventions for children 2005 and in 2013 it has reduced to 16, which is and adolescents. The MoHCC has developed a 2015 to ranked under “serious category” (GHI report 2013). 2018 acceleration plan for children and adolescents that In terms of trends in micronutrients, the typical diet in aims at reducing the prevention and treatment gaps Zimbabwe is deeply deficient in vitamins and minerals where targeted interventions and investments will be required for health, development and survival. The based on high yield results. national micronutrient survey of 2012 showed that the prevalence of among children aged 6 to 59 months in Zimbabwe was 72%. The results of the Nutrition survey further showed that children less than three MICS results indicate that there is a downward trend in years of age were the most affected by iron deficiency stunting prevalence from a peak of 35% in 2005/6 to with the age group of 6 to 11 months having a 27.6% in 2014 with noted disparities (ZIMSTAT 2014 9). prevalence of 81% and those aged 12 to 35 months Stunting remains high in rural areas (30%), compared to having a prevalence of 74%. 31% of children aged 6 to 20% in urban areas. Also worth noting are the gender 59 months had anaemia and the younger children 6 to disparities with boys having a higher stunting 11 months had the highest levels at 55%. Among the prevalence of 31.1% compared to girls at 24.1%. children who had anaemia, 67% also had iron Underweight and wasting remain stagnant at 11% and deficiency. 3% respectively (ZIMSTAT 2014). Figure 3 below further

40 35 30 25 20 15 10 5 0 Stunting Wasting Underweight Overweight

1999 2005-6 2010-11 2012 2014

Figure 8: Trends in stunting, underweight and wasting prevalence 1999-2012

ZDHS 1999, 2005/6, 2010/11, MNS 2012, MICS 2014

9 MICS

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Immunization 90 According to the 2014 MICS, overall, 69% of children 80.10 80 74.80 10 between 12 to 23 months of age were fully vaccinated 69.20 70 by their first birthday. Despite the fact that recent rates 64.50 60 show that the country has been in a positive trend in 52.60

e 50 terms of vaccination, there is still a significant number of g a t children that are not being fully vaccinated by their first n e 40 c r year. See figure 9 below. e

P 30

This positive trend is also seen in other vaccines. MICS 20 2014 shows that about 92% of children had received 10 BCG vaccination, 84.9% polio 3, 85.4% DPT3, 82.6% 0 measles vaccine. The positive trend can be attributed to 1994 1999 2005 - 06 2010 - 11 2014 the well-supported and well-coordinated Expanded ZDHS ZDHS ZDHS ZDHS MICS Programme on Immunisation (EPI) programme that Figure 9: Trends in % of children with all basic involves all major stakeholders, and a robust vaccine vaccination, Zimbabwe and cold chain management system. According to the Source: 1994 ZDHS, 1999 ZDHS, 2005-06 ZDHS, 2010-11 ZDHS and 2013 EPI Annual Report (Ministry of Health and Child 2014 MICS Care, 2013b), there were no significant stock outs of vaccines at the Central Vaccine Stores. This was confirmed by the VMAHS report of 2014 where 83.2% accidents (15% of disabilities in males and 9% in of the facilities – both rural and urban - had all the females). The known predisposing factors to disabilities required vaccines in stock (CCORE and UNICEF, 2014). during pregnancy include intake of certain medicines, drugs and chemical abuse including tobacco and Zimbabwe was also successful in introducing new alcohol) that may be harmful to the unborn baby, vaccines. The pneumococcal vaccine that targets one of micronutrient dietary deficiencies, and maternal illness the major killers, Pneumonia, was introduced in July during pregnancy (such as rubella). During delivery, 2012 and Rotavirus vaccine that is targeting Rotavirus prolonged obstructed labour and foetal asphyxia are diarrhoea was introduced in August 2014. major predisposing factors to childhood disability. Unborn babies exposed to these conditions are at risk of developing disabilities. Similarly, newborn and Childhood disabilities childhood illnesses (such as neonatal jaundice, febrile Disability, as a consequence of poor health and convulsions, ear and eye infections, measles and polio) nutritional status of children, often tends to be are well known potential causes of childhood overlooked when designing health and nutrition disabilities. It is noted that most of the causes of programmes. The three top causes of disabilities in disability are preventable and the health sector should Zimbabwe according to the 2013 disability survey 11 play a key role. MICS 2014 found that the coverage of conducted by MOHCC with support from UNICEF were interventions to manage disabilities are relatively high, diseases (42% of disabilities in males and 19% of although quality needs to be further improved and a disabilities in females), congenital/ perinatal causes focus on prevention is needed. The key findings of the (28% of disabilities in males and 19% in females) and disability survey revealed that the prevalence of disabilities in Zimbabwe stands at 7%, which is relatively low as compared to other countries in similar

10 Full vaccination includes the following: BCG, Polio, Pentavalent (DPT, settings but further research is necessary to clarify HepB, Hib) and measles. preventive measures. 11 Living Conditions among Persons with Disabilities Survey: Key findings report; MOHCC, UNICEF (2013).

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WOMEN’S HEALTH Table 3: Maternal Mortality Indicators for Zimbabwe, 2014 Maternal Mortality and Morbidity

According to the 2014 MICS, Zimbabwe’s Maternal MICS Indicator Description Value Mortality Ratio for the country stands at 581/100,000 Indicator live births in the five years preceding the survey and 614/100,000 in the seven years preceding the survey 5.13 Maternal Deaths during pregnancy, 614 mortality childbirth, or within two (see Table 3 ). ratio months after delivery or termination of pregnancy, The Maternal Mortality Ratio, which had previously been per 100,000 births within on a steady increase from an estimate of 520 in the the 7-year period early 1990s doubling to 1,068 (census 2002) and 960 preceding the survey per 100,000 live births (DHS 2010), began showing a downward trend for the first time in 2012. The UN Maternal Deaths during pregnancy, 581 mortality childbirth, or within two interagency group for maternal mortality estimates 12 ratio months after delivery or indicated that Zimbabwe’s MMR has gone down to 470 termination of pregnancy, per 100,000 live births in 2013 from 740 per 100,000 live per 100,000 births within the 5-year period births in 2005. A similar downward trend is seen in the preceding the survey estimates according to the census results, declining to Source: MICS 2014 (ZIMSTAT and UNICEF, Aug 2014) 525 per 100,000 live births (census 2012). The latest estimates from MICS 2014 stands at 614 per 100,000 live births. The variations in these figures are due to the differences in data collection methodology, but they all North and Mashonaland West provinces are affected fall within the same statistical range. While the decrease more by Obstetric Fistula compared to others. in maternal mortality rate is commendable, the rate is far According to the Zimbabwe Maternal and Perinatal above the global high MMR cut off of 300 13 per 100,000 Mortality Study (Ministry of Health and Child Welfare, live births and way above the Zimbabwe MDG target of 2007) the majority of maternal deaths (63%) occurred in 1990s level (174 per 100,000 live births). The National the postpartum period, 24% in the antenatal, and 6.6% Health Strategy gives the MDG target as 145 per in the intrapartum periods. Based on the 2013 HMIS 15 100,000 live births. In depth analysis of MMR figures data , 87% of the reported maternal deaths occurred in from 2002 and 2012 censuses shows that the slowest health facilities and 13% occurred at home, although decline in MMR has been for the age group of 15-19 the picture could have been distorted by under- years (13%) compared to overall decline of 49% for 15- reporting of community maternal deaths. 49 year age group 14 .

The WHO estimates that for every maternal death, there are 20 to 50 cases of severe maternal morbidity, one of which is Obstetric Fistula (OF). Obstetric Fistula usually afflicts the most marginalized women and girls i.e., 12 UN Interagency Maternal Mortality Estimates, 2014. Available at young, poor, often illiterate living in rural areas. http://data.unicef.org/maternal-health/maternal-mortality. Accessed on Octo - Prolonged or obstructed labour without access to ber 11, 2014. 13 Trends in Maternal Mortality 1990-2010; WHO, UNICEF, UNFPA & The emergency obstetric care is the most immediate cause World Bank Estimates of Obstetric Fistula. Obstetric Fistula is one of the most 14 Thematic Analysis of Census Data (not published) devastating consequences of a neglected childbirth and 15 Ministry of Health and Child Care, Health Management Information System, is a glaring example of health inequity in any society. A 2013. Data from this system comes from administrative records. Despite being a good source of information, data from this system has to be used carefully 2009 Fistula Needs Assessment carried out in since it does not take into consideration those cases that are not notified at Zimbabwe revealed that Manicaland, Matabeleland hospital. Therefore, chances are high that they hide cases that happened at home or in other facilities. That is one of the reasons why some indicators using HMIS are different from those using survey methods such as ZDHS and MICS, for example.

13 Health Development Fund Programme Document 2015

Leading Causes of Maternal Deaths Homes (MWH) for 3 weeks before and three days after delivery to increase their access to skilled birth The major direct and indirect causes of maternal deaths attendance and BEmONC services. continue to be the same through different years. The World Health Organization Global Health Data (2014 16 ) Other direct reported 2,100 maternal deaths in Zimbabwe in 2013 causes due to causes that are known, preventable and treatable Haemorrhage (see Figure 10 below). According to the organization, 11% Other indirect causes (malaria 34% major causes of maternal deaths were haemorrhage and HIV (34%), pregnancy induced hypertension (19%), unsafe 18% abortion (9%), sepsis (9%), indirect causes including AIDS defining conditions and malaria (18%), and other direct causes (11%). According to the Zimbabwe 9% Maternal and Perinatal Mortality Study (ZMPMS 2007) Sepsis 19% majority of maternal deaths (63%) occur in the 9% Hypertension postpartum, 24% in the antenatal, and 6.6% in the Unsafe abortion intrapartum periods. The same study also revealed that successful treatment of direct causes of maternal death Figure 9: Causes of Maternal Death, Zimbabwe could reduce maternal mortality by 46%. 2013 HMIS Source: WHO Global Health Data (2014) data showed that 87% of the reported maternal deaths occurred at health facilities and 13% at home, (although Quality of Care of Maternal Health Services the picture could have been distorted by under- reporting of community maternal deaths). The The most recent key maternal health indicators (MICS Zimbabwe Maternal and Perinatal Mortality Study 2014) shows that Zimbabwe has a high ANC coverage (Ministry of Health and Child Welfare, 2007) showed (94%), high institutional delivery (80%), high level of AIDS defining conditions as being the highest indirect skilled birth attendance (80%) and high contraceptive cause of maternal deaths. Although no local more prevalence rate (67%). Despite this high coverage, recent data on this is available, the above 2013 WHO MMR remains high. Although the high MMR can be global report points at HIV as a significant contributor to partly explained by high prevalence of HIV, the findings maternal deaths that cannot be ignored. of the most recent national integrated health facility assessment conducted in 2012 (NIFHA 2012), identified These observations emphasise the need for quality of care of maternal and neonatal health services strengthening the basic and the comprehensive as an area of concern. These findings emphasise the emergency obstetric and neonatal care (BEmONC and need to focus on continuing skills development, CEmONC) services along with the delivery of integrated mentorship and supportive supervision. SRH-HIV services in the country to reduce maternal and neonatal mortality and morbidity. The fact that majority The Quality of Care component of NIFHA 2012, which of maternal deaths occur at facilities suggest a possible included a component on direct observation, points to delay in arrival at the facility (second delay) including the the low coverage of BEmONC (6%) and CEmONC (7%) quality of care as a major associated factor leading to services across the country (providing all 7 and 9 signal deaths. For preventing and minimising maternal deaths functions respectively) along with poor quality of ANC, due to second delay, especially in rural areas, ZMPMS delivery and postnatal services. ‘Lack of money to pay 2007 recommended that all pregnant women in rural for treatment’ also explains part of high maternal areas in Zimbabwe should stay at Maternity Waiting mortality and morbidity, especially for the vulnerable girls and women in the society. ZDHS 2010-11 highlighted that this was a major concern for women 16 WHO Global Health Data, 2014, available at living in rural areas (59%), in lowest wealth quintile http://apps.who.int/gho/data/node.country.country-ZWE?lang=en (70%) and ones who had no education (75%).

14 Health Development Fund Programme Document 2015

The quality of care component of NIFHA 2012 more antenatal visits 19 . This represents an improvement assessment also pointed to the gaps in the knowledge from 93.4% and 56.8% respectively from the MIMS and skills of health providers on key maternal and 2009 data. The increased access to ANC services can neonatal health care. 47% midwives, 67% SRN and further improve maternal health if quality of care can 70% PCNs were not trained on EmONC. Only 21% also be improved. The NIFHA 2012 found that only 14% health providers knew about all the three components of health workers surveyed met the standard to identify Active Management of the Third Stage of Labour danger signs in pregnancy with only 4% and 2% (AMTSL). Complete knowledge on comprehensive inquiring for fever and convulsions respectively. Only newborn care was lacking as on average a health about 2% screened for pre-eclampsia signs. Of the worker could answer only 41% questions on observed health workers, less than half (46%) provided comprehensive new born care. all routine preventative medicines (Iron / Folic acid). Slightly more than a third (36%) provided education on Due to inadequate quality of care, Zimbabwe has birth preparation, while only 12% provided adequate reported 88 referred fistula cases of which only 59 were counselling on danger signs in pregnancy. repaired and more cases were not referred according to the fistula needs assessment conducted by the Ministry Despite the improvement in terms of access to of Health and Child Care in 2010. antenatal care, according to the 2013 HMIS, most of the women in the country have their first visit late in pregnancy. While the recommendation is that the first Maternal Death Surveillance & Response visit should occur before 16 weeks of gestational age, (MDSR) only 15% had their first visit during this period, 54% booked between 16 to 27 weeks, and 31% booked after An efficient MDSR system to identify and notify each 28 weeks. individual maternal death and to take appropriate action to avert similar deaths in future has an important role to The national standards and protocols for Focused play in reducing maternal mortality and improving Antenatal Care (FANC) that are in place, indicated that overall maternal health. A recent MDSR Assessment 17 in four provinces in the country identified the gaps in the existing MDSR system in the country, which were related to weak structures and capacity at facility and community levels to conduct maternal reviews. In addition, the assessment identified lack of resources for MDSR system and weak capacity to take appropriate action. With support from UNFPA (H4+) to MoHCC, efforts are underway to develop an electronic database for maternal deaths to strengthen MDSR system by ensuring real-time reporting of maternal deaths leading to prompt action. The existing DHIS2 platform used for national HMIS is being used for developing the database for maternal deaths so that this system can be fully integrated within existing HMIS and scaled up across the country. Antenatal Care

17 The 2014 MICS data shows that 93.7% of pregnant An Assessment of Maternal Death Surveillance and Response in Mashonaland Central, Manicaland, Midlands and Matabeleland North women 15-49 years of age were seen at least once by Provinces of Zimbabwe (Draft Report): 2014; conducted by MoHCC with skilled health personnel, and 70% attended four 18 or support from H4+, UNFPA 18 The World Health Organization (WHO) recommends a minimum of four antenatal care visits as the standard for the countries. 19 The country Target is 90% by 2015.

15 Health Development Fund Programme Document 2015

over 90% of all facilities offered key components of 100 routine ANC, but of the level 1 facilities only 31% tested 89.90 90 for anaemia and only 16% carried out routine urinalysis 79.60 for pregnant women, as compared to 73% of hospitals 80 70

testing for anaemia and 57% of hospitals doing urine e 62.80 g

a 60 analysis (MoHCC, 2012). t 54.60 n 51.80 e

c 50 r 43.80 Despite improvements, a large number of women still do e P 40 46.20 not receive the four recommended ANC visits. Social 35.70 30 and cultural practices and beliefs from different groups 19.30 in Zimbabwe contribute to a large group of women not 20 9.50 attending ANC. A second determinant is related to 10 financial access for those that seek ANC services. 0 Lowest Second Middle Fourth Highest Despite the current policy which advocates for free access, there are still places that charge for some Home % delivery in health facility services, and access to adequately staffed services is still an issue. Hospital facilities are not accessible for all, Figure 11: Comparison of home deliveries and health particularly for those that live in the most isolated and facility deliveries by wealth quintile, Zimbabwe, 2011 vulnerable areas. Further transport cost and its availability also impair access. Source: ZDHS 2011

Delivery showed that 68% of the deliveries were conducted by According to the 2014 MICS, almost 79.6% of births skilled personnel in health facilities. The Zimbabwe 2011 happen in health facilities, presenting an improvement Demographic and Health Survey (ZIMSTAT and ICF when compared with numbers from the 2011 ZDHS that International, March 2012) shows that the socio- indicated that 65.1% .Also according to the 2011 ZDHS, economic status is one determinant for being attended home deliveries are more common in rural areas (43% by a skilled health provider during delivery (See Figure of the time) as compared to urban areas (15% of the 13 and 14 below). 91% of the mothers in the richest time). According to HMIS, home deliveries significantly families of the country had the help of a qualified health decreased from 39% in 2012 to 24% in 2013 (See worker against 48% of the women in the poorest Figure 11 below). There is a social-economic families. Richest mothers-to-be in the country also have component related to home deliveries: the poorer a access to more skilled health workers during delivery mother is, the higher the chance that the delivery is than any other wealth quintile. going to happen at home.

Midwifery Skilled Attendant at birth The HTF supports midwifery schools to improve pre- service training and increasing the number of trained The 2014 MICS data shows that 80% women age 15-49 midwives in the country. However, gaps still remain in years with a live birth in the last 2 years preceding the strengthening midwifery regulation and association, survey were attended to by skilled health personnel at where strategic support can be provided to MoHCC and delivery of their most recent live birth (See Figure 12 the Zimbabwe Confederation of Midwives (ZICOM). below). On the other hand, the 2011 ZDHS found that only 66.2% of the births take place under the Access to a qualified health worker also varies supervision of a skilled provider. This number is very according to rural or urban area, as well as by province. close to the one found in the 2013 HMIS system that 86% of women in the urban areas had access to skilled

16 Health Development Fund Programme Document 2015

100 62.70 55.50 52.40 38.60 29.80 100 90.60 90 80 80.90 80 48.50

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70 a

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P 40 21.70 30 20 13.70 20 8.60 7.90 8.00 10 0 Lowest Second Middle Fourth Highest 0 Lowest Second Middle Fourth Highest Country Average Doctor Nurse Midwife Nurse

Figure 13: Type of skilled provider assisting during Figure 12: % delivered by skilled provider by wealth delivery by Wealth Quintile (%), quintile, Zimbabwe, 2011 Zimbabwe, 2011

Source: ZDHS 2011 Source: ZDHS 2011 providers during delivery in contrast with 58% in the The VMAHS 2014 (Ministry of Health and Child Care, rural areas. NIFHA 2012 highlighted that only 9% health 2014) reported varying levels of availability of basic workers took complete history during labour to identify EmONC services according to type of facility and all the danger signs and about 11% assessed for pre- location. In the urban areas, 100% of the Government eclampsia/eclampsia (testing urine for protein) during facilities, 40% of the local authority facilities and 33% of labour and delivery. The figure below (Figure 14) shows the mission facilities provided basic EmONC services. In how the provinces vary in terms of deliveries supported the rural areas, only 66% of the local authority facilities, by qualified providers, and by traditional birth 57% of the Government facilities and 42% of the attendants. mission facilities provided EmONC services.

17 Health Development Fund Programme Document 2015

within 2 days after delivery of their most recent live birth Percentage in the last 2 years. This number shows an improvement 0 10 20 30 40 50 60 70 80 90 when compared to previous years (according to ZDHS, 1.90 Bulawayo 88.40 43% of the mothers would have a post-natal care visit).

7.00 Despite an improvement in post-natal care, 23% of the 83.50 mothers still do not receive a health check after delivery, 6.50 7

Masvingo 5 .

2 and only 39% of mothers and 48% of babies delivered 0 Midlands 9.10 at home receive PNC (MICS 2014). 64.60 Matabeleland 6.00 South 71.60 Matabeleland 16.60 Remaining challenges in Maternal, Newborn, North 65.70 Child Health, Nutrition and HIV Mashonaland 13.90 West 55.00 Although the MICS 2014 results showed significant Mashonaland 21.50 East 59.90 gains in the revitalization of the health system, and Mashonaland 24.60 remarkable improvement in the key maternal, newborn Central 51.40 and child health, nutrition and HIV and AIDS indicators, 15.40 continued efforts are required to sustain the gains, and Manicaland 60.50

12.80 to avoid the risk of the health system lapsing back Zimbabwe 66.20 again.

Traditional birth attendant % delivered skilled attendant l The fact that 87% of reported maternal deaths occur in health facilities is just one example to Figure 14: % Delivery by Traditional Birth Attendant show that despite the improvements in coverage and % Delivery by Skilled Provider, of the interventions, and despite the good health Zimbabwe and Provinces, 2011 seeking behaviour of the Zimbabwean population, Source: Data for graph derived from ZDHS 2011 quality of care and equity of access still remain major challenge that need to be addressed. The proportion of facilities with mothers’ waiting homes Newborns continue to contribute significantly to also varied widely, with 100% of mission district l under-five mortality, and adolescents are not hospitals, 89% mission hospitals, 68% Government provided equal opportunity of access to health rural hospitals and 63% Government district hospitals care. having obstetric waiting homes. Significant gains have been made in adult ART The availability of ambulances for referrals was fairly l uptake, but the area of Paediatric ART, although good according to the VMAHS 2014 (CCORE and improved, still lags behind. UNICEF, 2014). Although none of the Government primary health care facilities had a functional l Health services at the rural health facilities has ambulance, 100% of central and provincial hospitals, greatly improved over the years, but the charging 98% of district hospitals, 95% of urban facilities and of user fees and the poor quality of services at the 85% of rural hospitals had functional ambulances. Provincial and tertiary hospitals has resulted in non-compliance to referral and increasing number of deaths reported at the higher level health Postnatal Care facilities. Despite consistently high immunisation coverage According to the 2014 MICS, 77% of the mother’s age l for all traditional antigens, the completion rate of 15-49 years had received a health check while in facility primary immunisation for infants has stagnated at or at home following delivery, or a post-natal care visit around 70%.

18 Health Development Fund Programme Document 2015 1 0 8 6 4 2 The coverages of health and nutrition 0 0 0 0 0 0 l % % % % % % interventions across the life cycle demonstrates a glaring of missed opportunities that still need to P r e FP be addressed. p r e

g AN C n Sustainability for the supply of essential drugs,

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n SEXUAL REPRODUCTIVE HEALTH a HI V/AI DS (in fant) t a

l AND RIGHTS Ear ly BF

EBF Family Planning

IYCF

MICS 2014 shows that the contraceptive prevalence IYC Fintr odu c on of… rate has improved to 67% from 64.9% in 2009,

accompanied by a reduction of unmet need from 13% IYCF- meal freq to 10.4% for the same period. This trend however does I n

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n not correspond to the increase in Total Fertility Rate c y from 3.8 in 2006 to 4.1 in 2011. While the society in IYC F - min AD general has a higher number of children wanted, MICS Measle s 2014 pointed out to a few challenges in provision of

DPT3 family planning services and promoting choice. First,

family planning method mix is heavily tilted towards Vit amin A short term methods, such as pills which sit at 43.9%. NO TStunted Second, unmet needs for youth (15-19) is higher than

SAM the average indicating a gap in promoting information

Care seeking and quality services for young people. Third, unmet needs for adults above 35 years old is among the Pneumonia tx. C

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o permanent methods. o d Dia rrhoea tx.

HI V/AIDS (Child ren… Adolescent Sexual and Reproductive health Birth Reg ist raon (ASRH) Above Pover ty lin e Zimbabwe has a youthful population, with 2/3 of the Imp roved sanit. (HH) population below the age of 25. The youth is one of the key affected population groups as most of the sexual ZIM Baseline (2014) Ne wTarget(2020) reproductive health indicators for youth are either deteriorating or remaining high, but also one of the key Figure 15 : Health Indicators by life cycle, baseline solutions to the problem the society faces taking into and target consideration the demographic dividend they can bring.

19 Health Development Fund Programme Document 2015

The adolescent fertility rate is estimated at 120 births Zimbabwe is currently rolling out voluntary medical male per 1,000 women aged 15-19 years which is the highest circumcision (VMMC) as a high-impact intervention for rate recorded since 1984. According to 2010/11 preventing new infections among young men in an Zimbabwe Demographic Health Survey, 20.5% of intense effort to circumcise the sexually active age women aged 20-24 years have had at least one live group between 15 and 29 years. The gains achieved birth before the age of 18 years. The rural-urban through this programmed need to be maintained differential in teenage fertility is striking, as rural girls beyond this so-called ‘catch-up’ phase and capacity were twice as likely to become a mother as their urban built in the public health system to provide VMMC to counterparts. The adolescent also has a high unmet new age cohorts as well as other age groups based on needs for family planning at 17% and low Contraceptive national policy and guidelines. Prevalence Rate at 10%. The decline of Maternal Mortality Ratio among women of 15-19 at 21% is much slower than the average decline of 43% for women of 15-49. HIV prevalence among young women aged from 15 to 24 is 6.4%, nearly twice as high than that among young men. Longitudinal data from the national sex work programme indicates that young female sex workers of the same age group experience an HIV incidence of more than 10%, ten times as high as the general population. All of these call for targeted and integrated sexual reproductive health information and service for young people.

HIV and AIDS

Despite significant improvements over the past 15 years, HIV remains a major cause of mortality, morbidity and maternal deaths in Zimbabwe. HIV prevalence among the adult population declined steadily to the currently estimated 15%, accompanied by a decline in incidence from an estimated 3.5% in the late 1990s to currently 0.98% in the general population. Young women experience higher HIV prevalence and incidence than young men at 6% prevalence and 1% incidence (2013 HIV estimates) in the age group between 15 and 24, indicating that innovative and comprehensive HIV prevention interventions remain a key element of ASRH programmes and require strengthening both at health system and community level. Longitudinal data from young key populations (CeSHHAR 20 programme data) indicates even higher HIV risk, with HIV incidence rates above 10% observed among young female sex workers, arguing that specific interventions to reach these vulnerable populations are required but not yet in place.

20 Centre for Sexual Health and HIV AIDS Research Zimbabwe

20 Health Development Fund Programme Document 2015

While HIV services are widely available in the country perpetrator of physical violence against women is the with e.g. HIV testing available in all health facilities, woman’s current or former husband or partner. 2010- service uptake needs to be strengthened to achieve 2011 ZDHS shows that women from all socio-economic ambitious targets like the 90-90-90 approach to testing and cultural background in Zimbabwe are subject to and ARV treatment adopted recently in the ZNASP III violence. Early and forced child marriages as which aims at increasing the percentage of diagnosed manifestations of violence against girls are on the PLHIV to 90% by 2020, and halving HIV incidence in the increase in Zimbabwe. The impact of this on girls and same period. young women are early pregnancies, high maternal mortality and high rates of school drop outs. Despite availability of key policy guidelines, critical programming Cervical cancer gaps like poor coordination and weak monitoring and evaluation system still exist. In addition, services for the In Zimbabwe, 4.37 million women in reproductive age survivor of GBV, like post-exposure prophylaxis, medical are at the risk of developing cervical cancer. Current services, psychosocial support, legal assistance and estimates indicate that every year 2,270 women are shelters are still very scarce in the country. A 2012 study diagnosed with cervical cancer and 1,451 die from the showed that only 3% women who suffered GBV disease. (WHO/HPV 2014 estimates). received any kind of professional help. Cervical cancer ranks high among the most frequent cancers in women in Zimbabwe. Under the ISP, the Ministry of Health and Child Welfare has been supported Remaining challenges in improving RMNCH-A to introduce and scale up Visual Inspection with Acetic Although these data indicate increasing coverage of Acid (VIAC) based cervical cancer screening services. In essential RMNCH-A services, there are areas of concern the past 3 years over 80,000 women have been regarding quality of care. For example: screened. The coverage of services however remains low. Only half of the districts currently have cervical l The percentage of women who had their blood cancer screening services. In addition only about 60% pressure measured and gave urine and blood of VIAC positive women received treatment (cryotherapy samples during the last pregnancy are reported at or LEEP). There is need to accelerate expansion of VIAC 52%. services, strengthen treatment of precancerous lesions l Tetanus toxoid protection is estimated at 64%, and link with treatment and palliative care services. and intermittent prophylaxis treatment for malaria at 6.4%, indicating missed opportunities to provide a full package of services to pregnant Gender Based violence (GBV) women attending ANC services. Zimbabwe has made strong commitments towards l According to the MTR Health Facility Survey, in eradicating violence against women and girls, especially 2014 only 44% of Primary Care Nurses (PCNs) in rape and sexual violence. The National Action Plan to Level 1 facilities have been trained in focused End Rape and Sexual Violence launched in 2014 and ANC. The target of the HTF is to train 80% of the 2010-2015 National Gender-Based Violence PCNs by December 2015. Strategy were designed to improve the efforts of the The new Post Natal Care recommended schedule Government and its development partners to prevent l of PNC visits on days 1, 3 and 7, and after 6 and respond to violence against women through an weeks of delivery is not yet being reported by effective and coordinated multi-sectoral response. facilities Despite these efforts, according to ZDHS 2010-11, 30% of women age 15-49 have ever experienced physical l Treatment of children who have ARI/pneumonia violence since age 15 and 18% of women experienced symptoms with antibiotics is only 34% it within the past 12 months. The most common

21 Health Development Fund Programme Document 2015

l Treatment of children who have diarrhea with ORT urban differential in teenage fertility is striking, as is only 56%, while treatment with ORT and zinc is rural girls were twice as likely to become mothers 14% as their urban counterparts. l Total fertility increased from 3.8 in 2006 to 4.1 in l 30% of women aged 15-49 have ever 2011. Unmet need for family planning for young experienced physical violence since age 15. people (15-19 years of age) at 11% is higher than Also, the high rate of early and forced child the national average. There is also high unmet marriages at 31% according to 2012 Census is needs for women above 35 years. a manifestation of violence against girls. Multi-sectoral service to survivors remain limited l The demand for cervical cancer screening in programme supported areas. exceeds the availability of services in public health facilities, only 9% of women of RH age l Access to comprehensive sexual reproductive screened up to now comparing with the target of health and HIV prevention and treatment services 35% to achieve an impact. by key populations, such as female sex workers, remain limited especially in public health facilities. l There are numerous fistula cases in the country of which only a minority has been repaired (from 88 It is important for the programme to address these cases reported to hospitals only 59 repairs were challenges in order to sustain the gains made so far in done 12 months before the MOHCC fistula survey improving the health care for children and women in the 2010, but many women have not even reached country. the referral level). Chapter 3 describes the overall aims and objectives of l The adolescent fertility rate is estimated at 120 the HDF within the context of the Ministry’s emergent births per 1,000 women aged 15-19 years which strategic plans from 2016 to 2020. is the highest rate recorded since 1984. The rural-

22 CHAPTER 3 The Health Development Fund - Overall Goal and Purpose

The Government of Zimbabwe within the overall framework of the Zimbabwe Agenda for Sustainable Socio-Economic Transformation (ZimAsset) seeks to improve the quality of health care of its people. Within this framework, the Ministry of Health and Child Care is developing its Strategic Plan (2016 to 2020). t is envisaged that the overall priorities will continue from the previous Strategic Plan (2010 to 2015) and that there will be opportunity to build upon the existing achievements. The National Health Strategy (NHS) is therefore expected to have an emphasis on RMNCH-A and Nutrition, SRHR, HIV, TB, and Malaria. The Ministry of Health and Child Care sees the NHS as a vehicle to further strengthen the health system especially for the reduction of maternal and child morbidity and mortality. In addition the MoHCC is likely to give additional emphasis to the following: l Burden of non-communicable diseases; l Strengthening of district and provincial hospitals; l Enhancing quality of services; l Preparedness for medical emergencies (such as Ebola, Cholera); l Implementation of Results Based Management (RBM); and l Enhancing Community participation.

23 Health Development Fund Programme Document 2015

In order to respond to the commitments above, there is Reproductive Maternal New born Child and Adolescent need for the Government of Zimbabwe to establish a Health (RMNCH-A); and nutrition interventions through clear long term framework for health financing. The support to the health sector. overall objective needs to be that of financial viability of good quality services, implementation of high impact low cost interventions and strong sector coordination. It Thematic Areas is also clear that if government is to achieve its Within this context the thematic areas of support will objectives for the health of the people of Zimbabwe, the also reflect continuity and build on the strong proportion of public expenditure allocated to health foundations that have been restored and improved needs to be increased to the Abuja target of 15% of the through the HTF and other programmes. These are state's national budget, and seek innovative ways of defined as follows: funding the sector more sustainably.

The HDF will contribute to the efforts of the Ministry of Health and Child Care in achieving the goals set in its Thematic Area 1: Maternal, New-born and Child National Strategy. Health, and Nutrition

Thematic Area 2: Sexual Reproductive Health and Rights The Health Development Fund Thematic Area 3: Medical Products, Vaccines and Aim: To support the Ministry of Health and Child Care in Technologies (Medicines and the context of the 2016-2020 National Health Sector Commodities) Strategy to achieve its goals of improving the quality of life of its citizens, through guaranteeing every Thematic Area 4: Human Resources for Health Zimbabwean access to comprehensive and effective (including Health Worker health services. Management, Training and Retention) Goal: To contribute to reducing maternal mortality (by 50%) and under-5 mortality (by 50%), by ensuring Thematic Area 5: Health Financing (Result-Based equitable access to quality health services for women Financing) and children by 2020; and to contribute to the reduction Thematic Area 6: Health Policy, Planning, M&E and of the unmet need for family planning to 6.5%, halving Coordination the prevalence of stunting in children under-5 and eliminating MTCT by 2020, combating HIV and AIDS, Thematic Area 7: Technical Support and Innovation Malaria and other prevalent diseases.

Chapter 4 provides more detailed description of the Purpose: To continue to consolidate and improve on intended areas of support within the Health gains made in maternal, new born child and adolescent Development Fund. (young people) health by strengthening health systems and scaling up the implementation of high impact

24 CHAPTER 4 Thematic Areas - Detailed Description

THEMATIC AREA 1: MATERNAL, NEWBORN AND CHILD HEALTH AND NUTRITION

The main priorities in terms of Maternal, Newborn and Child Health, and Nutrition are to consolidate the gains made through key high impact cost effective interventions, and gradually shift from ensuring that an adequate volume of services are delivered at the appropriate levels, to focusing on the continuum of care across the life cycle, greater quality of care and more equitable service accessibility.

25 Health Development Fund Programme Document 2015

These areas comprise the following interventions: w Ensuring that deterrents at the referral level enhancing Obstetric and Newborn Care; strengthening such as user fees and transport are effectively the Community Health Service delivery system; addressed improving the Expanded Programme on Immunization Supporting further human resources capacity (EPI) and Integrated Management of Newborn & l building by: Childhood Illnesses (IMNCI); and strengthening national capacity in Maternal, Infant and Young Child Nutrition. w Consolidating the clinical mentorship These interventions support ongoing capacity building programme and targeted on-the-job training to of MoHCC to improve, implement, supervise, monitor ensure that health staff provide adequate and evaluate national evidence based and best quality of care at the appropriate level and refer quickly when needed practices in order to raise minimum standards of health services for mothers, newborns and children. The main w Improving quality of antenatal care and interventions remain similar to those supported by the supporting the implementation of national HTF but with an appropriate change of focus to ensure policy on postnatal care that the successes achieved to date are maintained and w Support the training of nurse anaesthetists enhanced. Key activities in each intervention are as follows: l Support innovation and application of ICT in maternal health

Using M-Health for a pregnancy life cycle 1.1 Consolidating improvements in Obstetric w management approach and integrated and Newborn Care RMNCH-A/SRH/HIV services

A substantial number of midwives have now been With the number of mobile and smart phone users rising trained or upgraded; therefore, the focus will now be on fast the potential that mobile communication technology ensuring adequate coaching and mentoring support for (m-health) has in improving RMNCH-A programming in those staff to promote high quality of care and the country is huge. This covers a wide range of appropriate referral when required. District hospitals interventions including awareness generation, now have at least one doctor who can perform community mobilization and promotion, appointment Caesarean Section, so the focus will be on continuing to scheduling and reminders, mobile telemedicine to ensure that all appropriate supportive systems are in support staff in rural health centres, health management place for management of complicated obstetric & information services, health survey and surveillance, emergencies. Specific activities will include: patient monitoring, establishing Health call l Ensuring those geographical areas and in centres/Health care telephone help line, and Emergency particular districts hospitals if necessary showing toll-free telephone services. Once operational, m-health the lowest performance in service coverage are can reach a large number of people with earmarked targeted with additional support as these are services in real time and in a very cost effective manner, likely to include segments of the population most including improving programme management. Based at risk. the priority, in the initial phases of HDF implementation, l Strengthening the referral systems and support to together with GoZ, the specific m-health interventions referral points by: will be defined have to be agreed. w Improving the communication system and l Supporting midwifery association, regulation and establishment of a education to strengthen quality two-way referral system among each health l Improving quality of supervision, monitoring and service delivery level reporting by: w Considering the application of w Establishing a quality assurance system e-health technology, and

26 Health Development Fund Programme Document 2015

w Introducing RMNCH-A quality score cards activities and monitoring their impact focusing within the regular supervision system, and more on the use of patients charter and Ministry of Health and Child Care standards of quality w Strengthening facility and community based services and satisfaction indexes Maternal and Neonatal death surveillance and response, including identification, reporting l Strengthening and supporting a system to reviews and audits and the use of audit data to facilitate and monitor the VHWs in implementation improve decision making and action by of their roles, managers l Support broader community consultations on the l Improving essential newborn care at all health development of health services operational plans service delivery levels including at community and review the frequency of community feedback level by: on the progress made, feeding into the accountability mechanisms of RBF funding. w Ensuring that all health facilities conducting deliveries are equipped and staff trained in l Strengthening advocacy role of HCC and how this essential newborn care and management of can cascade to national policy advocacy through birth asphyxia the CSOs leading the programme. w Improving management of neonatal sepsis by l Support the development of conflict handling appropriate training and awareness-raising of mechanisms that track the conflicts and VHWs and ensuring rapid management or resolutions raised from the local, district, referral at primary care level

1.2 Further strengthening the Community Health Service delivery system for RMNCH-A and nutrition

Strengthening Community based health service delivery will continue to be a strong focus of the programme that empower communities to claim their rights and increase demand for appropriate quality services. A substantial amount of training to Health Centre Committees (HCCs) has been carried out and the country currently has about 11,000 VHWs who are now in place to support community based service delivery and improve communication between communities and health facilities. This has been done by the Global Fund and HTF, among other partners. The impact of these inputs will only be realised with strong efforts to consolidate, strengthen their capacity and cascade the communities’ demands to national policy advocacy. This will be done through community system strengthening of Global Fund and through support to districts by the HDF. Specifically for Nutrition, further training will be given under the nutrition component of the HDF. Activities will include the following: l Continuing to strengthen the effectiveness of HCCs by supporting ongoing capacity building

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provincial and national level. l Incorporation of the updated IMNCI TRAINING l Strengthen the use of social accountability tools package into pre service training into pre-service in order to improve the demand of quality training for the primary, clinical nurses and services and accountability at local health registered general nurses. centres. l Training on (follow up after training to district and l Initiation of integrated Community Case provincial health managers and master trainers) Management (iCCM) by: supervisory skills and development and distribution of IMNCI drug kits w Supporting newly trained VHWs to improve community awareness about services l Explore the possibility of introducing i-IMNCI for the country at village level. w Review/ develop appropriate guidelines on community management of illness and clarify l Scale up ETAT+ trainings targeting referral tasks, responsibilities and authority of VHWs hospitals w Ensuring adequate support for VHWs from the l Explore integration of ETAT+ into pre service health staff in the RHCs medical training w Strengthen community maternal death It has been proposed that GAVI in support of the EPI surveillance and response programme funding will subsequently be channelled through the HDF. This will not only complement the GAVI vaccine support that is currently procured by 1.3 Improving Child Health through continued UNICEF through the HTF and provide additional strengthening of EPI, IMNCI and ETAT+ resources for the Health Systems Strengthening, but will Substantial progress has been made on introducing new also ensure better coordination. Under this vaccines, expanding coverage of immunization, and arrangement, GAVI will subsequently be included conducting IMNCI training. The next phase will build on among the funding partners of the HDF, and the the successes in increasing vaccination availability and oversight of GAVI funding support will fall under the HDF coverage, and continue to strengthen IMNCI Steering Committee. This is still subject to Government implementation, specifically focusing on: approval. l Ensuring those geographical areas, in particular district hospitals if necessary showing the lowest 1.4 Consolidating gains in Paediatric HIV and performance in service coverage are targeted with AIDS and accelerating ART for Children additional support, and particularly reaching out and Adolescents to those mothers and children not accessing services due to geographical remoteness or Evidence based interventions that ensure service religious/ social beliefs integration and equity will be scaled up with a focus on results based management. These will be supported in Finding innovative ways of reaching the hardest- l line with the national acceleration plan for ART for to-reach populations children and adolescents. The key focus areas will be; Consolidating and strengthening the triaging l Improve the policy environment to facilitate system (fast-tracking the clinical care of very sick l accelerated and sustainable scale up of infant, children). paediatric and adolescent HIV care and treatment l Strengthening the link with the community health towards universal coverage in Zimbabwe system and the work of VHWs described above l Expand the provision of quality and l Improving awareness in health staff about comprehensive integrated Infant, paediatric and ensuring good overall health in children, and adolescent HIV and AIDS testing, care and actively seeking illness with each contact point. treatment

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l Strengthen the Human Resource Capacity at 1.5 Enhancing National Capacity in Maternal, national, provincial, district and facility level for Infant and Young Child Nutrition the accelerated scale up and universal provision Critical evidenced based nutrition interventions, scaled of paediatric and adolescent HIV care and up across the country through HTF have resulted in treatment improvement in nutrition service delivery system, l Strengthen paediatric and adolescent community contributing to progress in optimal infant and young systems for the provision and support for HIV child feeding practices, improved micronutrient care and treatment services supplementation coverage in children and mothers, and l Ensure the continuous availability of good quality management of severe acute malnutrition among young ARV medicines and commodities for the children. identification, treatment and monitoring of HIV The next phase will build on the successes and among children and adolescents specifically focusing on: Expand and improve generation, dissemination l Improving IYCF practices (IBF, EBF, Minimum and use of strategic information for infants, l Acceptable diet) both at community and facility children and adolescents level. Continuing to enhance implementation of l Strengthen infant, paediatric and adolescent ART growth monitoring and promotion using WHO program management, coordination and growth standard guidelines integrated with IYCF supervision l Implementation of the National Nutrition Communication strategy. l Improving the quality and care for children with SAM both enrolled for inpatient and outpatient program integrating with HIV l Increasing micronutrient coverage for young children and pregnant women ( IFA, vitamin A, zinc with ORS , scaling up food fortification interventions ) l Strengthening capacity of nutrition managers and implementers ( VHWs, district and provincial nutritionists) in knowledge transfers, skills development and supportive supervision through differential strategies which will include mentorship program, monthly review meetings with corrective actions and feedback system and training on identified gaps ) l Improving quality of Nutrition information system at all levels l Demonstrating multi sectorial community based approach model to reduce stunting in selected vulnerable districts with a special focus on: w Addressing context specific drivers of stunting through the capacitated coordination structures at community level and with the involvement of the communities themselves

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w Interventions to be targeted at the nutritionally- w Child Marriages at risk households (i.e. vulnerable pregnant Improving geographical access: considering and lactating women, children under 2 years of w task shifting and task sharing, and paying age, adolescent girls) particular attention to those areas that are w Integrated response to stunting through performing below target in achievement of key convergence of multi-sectoral services (health, indicators agriculture, WASH, social protection, education gender) provision at the household w Promoting health seeking behaviour, level for greater synergy between services addressing factors impeding access and acceptance of health services (religious and w Effective use of available resources and other socio-cultural groups) through targeted leveraging additional resources for improved awareness-raising with local leaders and key nutrition outcomes stakeholders w Capacity building of existing multi-sectorial w Addressing emerging urban health challenges government structures as identified in the and those of peri-urban poor, and seeking to Food and Nutrition Security Policy and disaggregate data from these groups National Nutrition strategy compared to the overall urban population. w Childhood disabilities: There will be further 1.6 New possible activity areas: support to improve timeliness and quality of If additional funds are available, the following activity antenatal care, skilled delivery, prevention and areas will be supported: early treatment of childhood illnesses as key interventions for preventing childhood l Supporting the preparedness and response to disabilities. At risk babies exposed to communicable diseases outbreaks through the conditions that predispose them to childhood overall health system strengthening work of the disabilities will be followed up and provided HDF through: with special care to prevent progression to disabilities. Special attention will be given to Improving communication networks and alert w early identification of developmental delays systems for disease outbreaks and referrals to appropriate community based w Strengthen service providers capacity to apply rehabilitation services. Those who may minimum initial service package for eventually develop disabilities will be referred reproductive health during emergency (MISP) to specialized services for rehabilitation. l Provision of selected high impact intervention on Non-Communicable Diseases (NCDs), for example: THEMATIC AREA 2: SEXUAL w Early detection and treatment of hypertension and diabetes REPRODUCTIVE HEALTH RIGHTS l Addressing a range of cross-cutting factors that This pillar seeks to strengthen availability of and access influence RMNCH-A outcomes, for example: to voluntary family planning services, especially long acting contraceptive methods (LAM), improve and Addressing patient, maternal and child rights: w expand post-abortion care and post abortion FP ensuring free access to health services. services, strengthen integrated information and services w Making birth registration available within health in MWHs, strengthen cervical cancer prevention. Fistula facilities. prevention, treatment and social re-integration will be w Addressing violence and abuse - prevention added. Provision of youth-friendly sexual reproductive and care health services and scale up of integrated SRH-HIV

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services, especially for adolescents and key populations will be strengthened. , It will also support the catch-up as well as the sustainability phase of VMMC. The pillar will also continue to strengthen demand generation and behaviour change communication for key SRH issues, especially through further integrating community interventions for SRH such as Behavior Change Facilitators (BCFs) programme. It will consolidate gains made under the Integrated Support Programme, the Global Programme for Reproductive Health Commodity Security and other SRH programmes. Lessons learned from ISP will be applied through both public and private sector service delivery in the different areas.

2.1 Family Planning One cost-effective and key intervention in reducing maternal mortality and neonatal mortality and morbidity is family planning. Focus of the programme will be on l Support to the revision of relevant protocols and increasing coverage and quality of FP information and guidelines for FP, especially for LAMs services for hard-to-reach and marginalized populations l Supporting FP trainings, complemented by including adolescents, promoting choice and supportive supervision to increase the number of strengthening method mix, especially to enhance the trained and skilled FP service providers at primary availability of long acting methods (LAMs) of family health care level, especially on LAM planning, including during postpartum and post- Improving access to FP services for HIV positive abortion periods. In line with the unmet need for l women by better integrating SRH and HIV spacing among young women and girls and the unmet services, e.g. increasing FP service provision in need for limiting among women above 35 years of age, OI/ART settings. efforts will be made to make appropriate FP methods more accessible to them. Proposed interventions l Improving access to a minimum package of high include: quality youth-friendly SRHR services by young people at health facilities as per the principles of Support to implement, monitor and report on the l continuum of care. The minimum package, FP strategy and the national action plan. delivery modality and specific targeting of SRHR l Support to strengthen capacity of relevant services will be informed by the ongoing national national institutions to be fit-for-purpose and to adolescent fertility study and the ASRH effectively lead, regulate and coordinate family interventions review. Reducing unmet need for FP planning programmes and services for achieving among adolescents aged 15-19 will require multi- FP2020 sectoral efforts beyond the health system which l Provision of family planning commodities and are further elaborated in the Joint Programme on diversifying choices of contraceptives, taking into Youth currently being developed by the UN account specifics in unmet need and diverse age agencies in Zimbabwe (see ASRH section). groups. l Outreach services – to reach closer to the client l Strengthening supply chain management, through subject to availability of evidence especially from support to the DTTU and a transition from push religious objectors. to pull system

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2.2 Post Abortion Care 2.3 Strengthening maternity waiting homes services In addition to ensuring that unmet needs for family planning are addressed, post- abortion care services will Building on the revitalization of maternity waiting homes, be focused on in terms of improving the quality of supported under the EU MDG Initiative, maternity service provision. waiting homes services will be strengthened. Key activities will include: With the overall goal of reducing maternal mortality in the country, the focus of support is to 1) prevent l Scale up refurbishment of MWHs in hard to reach abortion through greater investment in programmes for areas elimination of teenage pregnancy and child marriage l Enhance the use of maternity waiting homes to complemented by specific family planning programmes link communities with the health system to targeted towards young boys and girls; 2) advocate to achieve quality continuum of care. simplify the legal and bureaucratic procedures l Support quality integrated SRH/HIV/GBV governing legal abortion; and 3) improve the quality of information and services at MWHs, especially for post abortion care services, especially through: adolescents who are pregnant. 1. Aligning post abortion care services in accordance l Men involvement and improvement of their role in with the internationally agreed expanded package of the Maternity Waiting Homes post abortion care 21 that comprises the following components: 2.4 Cervical Cancer Prevention a. Treatment of incomplete and unsafe abortion and complications; Based on the success and lessons learnt in the Integrated Support Programme, the MOHCC will be b. Counselling to respond to women's emotional supported to scale up the VIAC based national cervical and physical health needs; cancer screening programme and treatment of pre- c. Contraceptive and family planning services; cancerous lesions. Referral mechanisms to advanced care at tertiary hospitals will be enhanced. The d. Reproductive and other health services; programme will promote integrated SRH service using e. Community and service provider partnership the VIAC centres established. Key activities will include: to prevent abortion and respond to abortion l Development or revision of guidelines and needs protocols on cervical cancer prevention 2. Revising post-abortion national guidelines l Capacity building of health workers on screening using VIAC and treatment of pre-cancerous 3. Building capacity of health service providers to lesions with cryotherapy and LEEP provide post abortion services (especially on the use of Manual Vacuum Aspiration - MVA) l On the job support and mentorship Procurement and distribution of VIAC equipment 4. Ensuring the availability of medical supplies, l and consumables to establish additional VIAC including MVA kits in health facilities services with the aim of at least two hospitals in each district providing VIAC l Integration of cervical cancer services with HIV, RMNCH-A and FP

21 Post abortion Care Consortium Community Task Force. Essential Elements l Strengthening linkages with other cervical cancer of Postabortion Care: An Expanded and Updated Model. Postabortion Care prevention activities like HPV vaccination Consortium. July, 2002 l Strengthening referral mechanisms to advanced

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care at tertiary hospitals and addressing barriers under this pillar is to support treatment and re- to access integration through increasing availability of obstetric fistula repair services to vulnerable women, and mitigating the effect of obstetric fistula. Key activities 2.5 Adolescent Sexual and Reproductive will include: Health l Refurbishment of theatre facilities to provide Support to ASRH requires a multi-sectoral response, obstetric fistula services at selected hospitals such as health, education, vocational skills and work Obstetric Fistula Camps for affected women with communities. The UN is drafting a joint programme l that will act as a vehicle for multi-sectoral engagement l Develop a training programme for doctors and around youth development. While the joint program is nurses on simple obstetric fistula repair and post- still to be finalised, the proposed focus is on outcomes operative management such as reducing adolescent fertility and child marriage. l Work with community cadres to increase The support to strengthen ASRH information and awareness of available services in communities services through the HDF will focus on health sector and among affected women, facilitate access to interventions and the community for improving the services and socially re-integrate women overall wellbeing of young people and reducing teenage following obstetric fistula repair pregnancies. Specific focus will be on:

l Establishing standards for YFHS based on 2.7 SRH-HIV integration international/regional standards The focus of this area will be on a) roll-out of the service Enhancing skills of health workers in l provider SRHR and HIV linkages capacity building to communicating effectively with youth and ensure that SRHR and HIV integration is part of day-to- providing youth-friendly services day service provision in both (SRH and HIV) settings, l Supporting community workers and gatekeepers and b) scale-up of an integrated SRHR and HIV linkages to work with youth in communities and facilitate model focusing on STI and HIV prevention among their access to appropriate services, including FP pregnant and postpartum women in maternal health l Link with HPV vaccination services. services, and building on the current initiatives under the maternity waiting homes. In addition, the SRHR component for adolescent and youth will cut across different thematic areas, such as family planning, HIV, GBV, etc. As new evidence is Key activities being generated through the joint review of ASRH interventions and the teenage pregnancy study in 2015, l Strengthening use of maternity waiting homes to the HDF will support new interventions and innovations link communities with the health system for adolescents and youth beyond the three proposed continuum of care, health promotion and SRH- interventions above. HIV services (ANC, PMTCT, HTC, delivery, post-partum family planning, cervical cancer). Strengthening prevention of unintended 2.6 Obstetric Fistula l pregnancies among women living with HIV (prong Fistula prevention, treatment and social re-integration 2 of PMTCT), and HIV prevention among HIV will be supported. Prevention of obstetric fistula is negative young women in ANC settings (Prong 1 mainly through improving quality of maternal health of PMTCT) care, including EmONC and addressing the three l Scale up of an integration model developed under delays. Quality maternal health care is covered under the ISP and Linkages programmes into health the RMNCH-A thematic area. The overall objective facilities at district level including urban facilities

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l Service provider capacity strengthening on the l Support for national programme coordination syndromic STI and RTI management approach, Support for policy development and stakeholder condom promotion and safer sex negotiation, l engagement especially the education sector management of SGBV, provision of integrated youth -friendly SRH and HIV services l Integration of VMMC into male-friendly SRH and other PHC services as well as PNC for EIMC (to Strengthening service provider capacity to l be determined based on currently outstanding provide stigma-free and appropriate integrated policy decisions) SRHR services to key populations, where indicated in innovative settings. l Training and refresher training of health workers in all districts including urban areas l Capacity building of managers in facilitative supervision and mentorship l Support for quality assurance and cascaded supervision Maintaining functional referral systems for 2.8 Voluntary Medical Male Circumcision l adverse events HDF will continue to support the remaining catch-up l Replacement of reusable instruments and where effort of VMMC through private sector interventions in indicated procurement of devices the initial phase of the HDF. Meanwhile, to ensure continued availability of VMMC services beyond the l Mass media for demand generation for MC during the transition period from private sector to public catch-up phase, capacity of the public health system sector delivery models will be strengthened to provide surgical and device-led VMMC services to targeted males, based on national l Support for generation of evidence as well as policy and strategic recommendations. This requires modelling based on emerging information

2.9 Gender Based Violence

Similar to ASRH interventions being multi-sectoral, the support to eliminate GBV will be provided through a multi-sectoral GBV prevention and response programme. The programme will focus on elimination of sexual and gender-based violence as well as child marriage through 1) improve GBV and child marriage prevention mechanisms; 2) strengthen access to and availability of integrated, comprehensive and survivor centered GBV services; 3) strengthen GBV multisectoral coordination and 4) enhance monitoring, evaluation and knowledge management. Key interventions include the following. l Support the Ministry of Women Affairs Gender and Community Development to coordinate a multi-sectoral gender-based violence prevention and response programme at national, provincial and district level, with special attention to sexual violence and child marriage. It will promote three Ones through strengthened coordination, namely, One GBV response framework, One GBV coordinating body and One M&E framework;

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l Further integrate prevention of gender-based to establish/enhance One Stop Centre at violence and child marriage in community-based provincial hospitals; Strengthen the referral demand generation programmes with community pathway to enhance integration of services in leaders, faith-based organizations and other health facilities through training and mentorship; community gate keepers. Support procurement of essential commodities such as pregnancy and HIV test kits, PEP kits; l Seek opportunity to integrate prevention of GBV and Strengthen routine M&E system in reporting and child marriage in the comprehensive sexuality cases of GBV in health sector through reviewing education programme for young girls and boys existing tools and then providing capacity and the newly launched parent-to-child building to address gaps. communication programme. l Last but not least, the programme will build the l Support the national campaign to end child capacity of national institutions, mechanisms and marriage including enhanced advocacy for policy civil society organizations to monitor the national change and alignment and enforcement of age of gender-based violence strategy with a focus on marriage to the new constitution. confidential data management and harmonized l Build the capacity of national institutions, data collection. It will also support the Ministry mechanisms and civil society organizations to of Women Affairs and Gender to strengthen provide quality, integrated and survivor centered knowledge management on GBV through training, services as per national guidelines, which include research and regular dissemination of programme but not limited to legal aid, police and health results and experiences. services. l Support will be provided to strengthen and scale up one-stop centers and community shelters for integrated services, integrate GBV and SRH 2.10 Community interventions services in Maternity Waiting Homes, and Community interventions under the SRHR theme will integrate GBV services for key populations. The aim at generating demand for HIV & SRH services and programme will scale up support to capacity creating an enabling environment for service uptake building of service providers in the referral especially for young people and key populations pathway on the survivor centered principles and through existing community based cadres 22 . approaches. It also aims at fostering team spirit among service providers to enable a coordinated The HIV&SRH community interventions will include: and seamless referral process, guided by the Continuation of the home visit approach same principles. The programme will strengthen l implemented under the ISP, with additional collaboration and build capacity among police emphasis on reaching young people and judiciary to improve survivors’ service access and case management including improved l Support for task shifting and community-based access to legal abortion; service delivery of key SRH services through the community cadres engaged in home visits. l Health sector response which was lacking in the past will now be scaled up. Key activities include, l Enhanced outreach and mobilisation for key among others, capacity building of health care populations, especially young sex workers, workers in clinical care and management of GBV combined with appropriate models of service including sexual violence with the aim of making delivery and programme evaluation. the services available at least in each district and provincial hospital; Sensitization of Health workers at primary health care centres, including 22 A study to map community cadres across health and GBV interventions is local government clinics on screening for GBV under way and will make recommendations towards a comprehensive commu - nity systems strengthening approach. Currently proposed roles of community and making appropriate referrals; Provide support cadres will be revised based on the findings of the study.

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l Engagement of community leaders as agents of area of support in the consolidation phase. Although change through training and promoting their much of the infrastructure and equipment is already in active leadership in reducing cultural and social place there is need to support their service and access barriers to SRHR service uptake. maintenance, linked to the Results-Based Financing mechanism that is being rolled out since mid-2014. The HDF will facilitate dialogue and programming with Selected medical equipment will be procured only in concerned Ministries which host different community case of acute shortage, as most of the supported health cadres with an aim to integrate community workers facilities at primary level have already been equipped to through one service package for RMNCH-A, one provide basic RMNCH-A and nutrition services under coordinating body, one budgetary framework, one the current HTF and other UNICEF interventions performance management system and one M&E system (including EmONC, neonatal resuscitation and newborn to achieve efficiency and effectiveness of voluntary corner equipment (including kangaroo care), walk-in health extension workers in the communities. This will cold rooms, programme vehicles, solar refrigerators, influence the design and implementation of pro poor quality assurance and testing equipment, bicycles for health policies. Village Health Workers). Apart from the procurement of vaccines, the GAVI support through the HDF will be 2.11 Advocacy work utilised for supporting EPI cold chain, logistics and other equipment, as well as their routine maintenance. Advocacy interventions around all aspects of SRHR but prioritizing child marriage, access to legal rights for UNFPA will continue to support medicines and SGBV survivors, and improving service access for commodities for programmes such as the Maternity young people and key populations have been ongoing Waiting Homes (refurbishment), the H4+ (maternal and will continue under the HDF involving partners such health drugs, MVA kits and other equipment e.g. as the National AIDS Council, MOHCC, MWAGCD, and anaesthetic machines) and the Global Programme for civil society. Support will be provided to work with law Reproductive Health Commodity Security (family makers as well as judiciary, police and health service planning commodities, oxytocin and magnesium providers, complemented by interventions at community sulphate). Additional commodities to be procured level targeting gatekeepers such as traditional and through UNFPA will include STI medicines stipulated in religious leaders. the revised national guidelines on syndromic management of STIs and Reproductive Tract Infections (RTIs), but have not traditionally been included in the THEMATIC AREA 3: MEDICAL primary health care kit. PRODUCTS, VACCINES AND The main objective for the next phase is to ensure the TECHNOLOGIES (MEDICINES AND current high levels of availability of essential supplies is COMMODITIES) maintained, and a more efficient and appropriate supply The objective for Thematic Area 3 still remains to chain mechanism is established. maintain the availability of 80% of essential medicines and commodities (the selected package based on the WHO recommendations applicable to Zimbabwe) and Key activity areas include the following: 100% of vaccines and injection equipment, cold chain l Explore the possibility of a single harmonised equipment and nutrition commodities in all health supply chain management system for the country. facilities across Zimbabwe. Reproductive health commodities will be included. l Continue the procurement of essential medical products, vaccines and technologies (medicines, Medical products, vaccines and technologies nutrition commodities and consumables (medicines, blood products, health commodities Support the ongoing transition from a push to an including nutrition supplies) will continue to be a main l assisted pull system of ordering of medicines and

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other commodities, following up on the results of THEMATIC AREA 4: HUMAN the pilot implementation in Manicaland and RESOURCES FOR HEALTH (HRH) scaling up good practices across the country (INCLUDING HEALTH WORKER l Consider expanding the current bulk items to MANAGEMENT, TRAINING AND provide adequate amount of EmONC medicines RETENTION) and consumables, and second line and With an economy that is still ailing and with no emergency maternal and paediatric drugs that are immediate likelihood of wage increases, it is clear that required to manage critically conditions for both the critical staff retention scheme will remain as another the mother and the child. major area that requires support to ensure adequate l Encourage further linking and integration of HIV- numbers of appropriately trained staff are in place. The related services to the general health system and possibility of financing the HRH retention packages facilitate a comprehensive approach to through RBF is an area the government and partners antiretroviral supplies and overall health of may wish to consider, with a view to developing a more mothers and children cost effective system. l Strengthen forecasting, procurement, storage and There will be less focus in future on the in service distribution and monitoring of RMNCH –A drugs, training of midwives, since the ‘manageable quota’ for vaccines, blood products, health and nutrition midwives has almost been reached in the current HTF. commodities. Similarly, there will be less focus on the training of l Strengthen Logistics Management Information prescribers on clinical IMNCI, and any further gaps will System (LMIS) and reporting for all health be filled by WHO and other partners. However, a commodities national assessment of remaining training needs is required in order to assess overall progress to date, so l Strengthen product selection, forecasting, that remaining priorities are identified and only specific procurement, storage and distribution and targeted needs will be addressed in the extension monitoring of RMNCH –A drugs, vaccines, blood phase. products, health and nutrition commodities. Therefore, the key objectives of the next phase will be to Strengthen Rational Medicines Use, Rational l ensure that the current trend in reducing vacancy rates Blood Use and Rational Nutritional Commodities is maintained and improved, and that health staff are Use. able to provide a minimum level of quality of care that is l Support the ongoing quality assurance activities regularly assessed. including pharmacovigilance, reporting on Key activity areas include the following: adverse drug reactions (ADRs) and adverse events following immunisations (AEFI). l Completing the Workload Indicators of Staffing Need (WISN) assessment and support implementation of findings within the national Human Resources planning framework and the revision of the national health strategy. l Reviewing of the approach to post-basic, in- service training at national level so that there is a nationally coordinated, provincially implemented training programme covering all appropriate subjects; it should seek to ensure appropriate numbers of adequately trained staff at all levels while minimising duplication, time away from station, and concentration of knowledge in a few cadres.

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l In consultation with the schools or universities, still in the process of being established and tested effort will be made to incorporate the in-service across the country, building on the experience in 18 training into pre-service training and revision of districts supported by the World Bank. In consultation curricula to include changes and new with World Bank, the next phase will need to ensure that developments in RMNCH-A and SRHR. an effective and efficient system is in place. It is proposed that, whilst support will continue to be given Ensuring continued retention of key staff and l to other non-staff running costs at the primary and first increase dialogue for fiscal space for government referral levels through the RBF system, this subsidy contribution. should be focused on the Primary Care facilities. The l Supporting the current review of the retention extent to which the use of these resources is system at national level to ensure a gradual move performance related, and at what level, requires further towards a sustainable, comprehensive, nationally consideration including consistency with overall RBM driven, equitable system of provision of fair wages and Health Financing policies. and benefits to all health workers driven by the Government of Zimbabwe. This will include and At the rural clinics there is almost full coverage of free will not be limited to consideration of what can be services but patients referred to the higher levels still reduced, increased or phased out. This will have to pay for these services. The full removal of user ensure that there is more value addition to the fees continues to pose a challenge for higher level investment. Consideration of linking with thematic facilities since the available funds are not sufficient to area 5 on the possibility of paying for staff based cover their running costs. This issue still needs to be on performance will also be explored. addressed. A voucher mechanism is proposed as a l Ensuring adequate mentoring to health staff and possible solution for referrals. Notwithstanding the regular supportive supervision to health facilities. Government policy, Urban Health Centres are more likely to charge fees. However, where there are pockets Mentorship programmes will continue to be l of vulnerable populations within the urban and peri- supported on all thematic areas and include all urban centres, innovative ways could be used to levels of service delivery, from community level to address accessibility issues. referral centres. During the first year of the implementation of the HDF a Cost Benefit Analysis which includes quantitative and Key activities include: qualitative analysis of the benefits attained by the Use the findings of a process evaluation to be Programme will be conducted. l conducted in 2015 on the current PIM to improve the implementation modalities of the RBF and THEMATIC AREA 5: HEALTH also possibility of implementation of RBF in the FINANCING (RESULT-BASED district hospitals and the referral chain. FINANCING AND OTHER l Enhance the RBF mechanism in RHCs including INNOVATIVE HEALTH FINANCING closing the gaps in training at all levels based on MECHANISMS) the RBF Project Implementation Manual and the disadvantage of low volume and remote clinics. The objective for this Thematic Area is to improve national capacity for health financing across all health l Considering performance-based strategies for service delivery levels with special emphasis on the other funding support, e.g. District Health most peripheral health facilities, primary health centers Executive Teams, Provincial Health Executive and district hospitals. Teams Ensuring adequate learning from the RBF The current HTF provided funds to RHCs and District l experience to inform a future plan for Hospitals on a regular basis, but introduced a RBF performance-based strategies in the health sector approach for RHCs in mid-2014. As this mechanism is

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l Supporting the overall approach of government- l Support provided to further strengthen the routine led Results Based Management (RBM) and Health sector M&E system, to strengthen the Health Financing. routine HMIS (DHIS-2), PMD generic report, National MODO and provincial review and Consider a voucher system for referrals from l planning meetings, and the annual joint review clinic level and building on lessons learnt from missions. existing voucher systems in the country, for example the World Bank RBF project. l Providing support to a full programme of PHT and l Use RBF to influence priorities and continuously DHT Meetings review indicators that it rewards. l M and E planning and consolidation of the l Linking RBF to strengthening community different M and E strategies within the Ministry participation component so that there is disclosure of resources to communities, progress l Data generation including the linkage of DHIS and on the use and future ambitions. the RMNCH-A scorecard l Consideration for phasing of out RBF from being l Support for the national task force teams which managed by external partners to be managed have a direct influence to RMNCH-A and provide within the Ministry of Health and Child Care thus guidance to good governance in the task forces making RBF more sustainable. l Revision of policies, strategies and guidelines as guided by the 2016-2020 National health strategy e.g. HR, Health Financing, Quality Assurance and Improvement strategies, RBF national guidelines THEMATIC AREA 6: HEALTH l Revise the current Vital Medicines and Health POLICY, PLANNING, M&E AND Services Availability Survey to include the SRHR COORDINATION commodities and to make the survey more The cohesion and coherence of direction achieved relevant in the HDF. through the HTF needs to be continued, and if possible l Coordination of the supply chain management extended across the whole health sector. The and data generation. leadership, coordination and accountability aspects of these arrangements need to be strengthened at the l Consolidate the quality improvement, quality provincial level and below through the full restoration of assurance and infection control activities as effective Provincial Health Team (PHT) and District guided by the national health policy and strategy Health Team (DHT) arrangements, and such for quality in health. strengthening of management at these levels that will The progress so far achieved, for the women and permit increased delegation from the national level. children’s health status indicate that any further Thus, the key objective of this thematic area is to ensure progress will require more support especially in comprehensive and inclusive governance of the health supervision, quality standards and monitoring. It also sector with an appropriate level of decentralisation requires that the health facilities and the health system established and accountability mechanisms be robust, with a two way referral system at each level Key activities of the health system and identifies the most efficient ways and new ways of doings things. Technical support Providing technical support to the MoHCC to l and innovation as described in the subsequent section generate the necessary evidence in order to will be critical to achieve this. develop evidence based strategic and annual work plans

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THEMATIC AREA 7: TECHNICAL and building of synergies in line with HDF SUPPORT, OPERATIONS RESEARCH objectives AND INNOVATION l Provision of short term technical assistance for key areas It is envisaged that a small flexible fund will be available l Facilitate the development of Public-Private to support improvement in key aspects of health service Partnerships delivery with a commitment to reduce mortality and Incentivise and reward innovations morbidity particularly in the “hardest to reach” client l Operations research on linking health care groups and geographical areas. This fund will support l financing policy and RBF technical assistance and vanguard implementations and Innovative approaches to learning and evaluation. The fund will be available to government and l mentorship, e medicine, e-learning. non-government organisations and may also be useful Design methods and ways of reaching the in schemes that will help to maximise the impact of l populations in peri-urban settings. health services funded through other initiatives (e.g. HIV / AIDS; TB; Water and sanitation projects; etc.) including l Setting up a near real time monitoring system spatial mapping of partnerships. under the Multi sectoral Community based programme to reduce stunting.

Key activities: Health Systems Blocks l Support interventions to address issues and recommendations arising from Joint Review It should be noted that the thematic areas seek to follow Missions. the health systems blocks as given by WHO with l Provide support in the design and roll out of thematic area 1 and 2 being the services, thematic area operational research on key RMNCH-A areas 3, covering the medicines and technologies, thematic where there is paucity of information to facilitate area 4 covering the Human resources for Health, innovative responses and approaches thematic area 5 covering Health Financing and Health l Provide technical support to generate evidence Information strengthening, thematic area 6 for base from local and global sources that can be leadership and governance and thematic area 7 for used for policy dialogue information. l Innovations around inter-sectoral Tcohlleab WoraHtiOon sHealth System Framework

Access Service Delivery Service Health Workforce Improvement Health

Information Responsiveness

Medical Products, Vaccines and Social and Financial Technology Risk Protection

Financing Improved E!ciency QUALITY Leadership/Governance SAFETY

The WHO Health System Framework

Source: Adapted from the World Health Organisation

40 CHAPTER 5 Cross Cutting Issues

Across these thematic areas, there will be specific attention paid to:

Focus on Quality: In spite of the quantitative improvements that the health sector has documented over the last two years, improving effective quality coverage still remains as a major challenge. Therefore it will be important to focus on consolidating the gains realized so far in order to improve the quality of health services provided to the community. There is need to start focusing on targeted capacity building of government, with particular emphasis on improving the knowledge, attitude and skills of health and administrative workers at the district and provincial hospital level through on the job training, clinical/ technical mentorship and regular supportive supervision. At the primary care level, there is a need to accelerate progress in training PCNs to address the quality gaps observed in ANC/PNC services. This process has started and needs to be fully implemented and consolidated. The attitude of health workers has been presented as a major concern in several annual review meetings and at this juncture this requires urgent attention. To begin with, it may be wise to start providing an in-service training on medical ethics and professional orientation to all practicing health workers and administrators at all levels. This would be complemented by the strengthening of HCCs, client satisfaction assessments, and the use of community accountability mechanisms, such as the community score cards.

Focus on Equity: The health system still needs to address the disparities due to: geography, wealth, religion and other socio-cultural factors, and age. There is limited geographical access to health care for certain communities due to distance, terrain/rainy season. Most of the service coverages are lower in rural areas as compared to the urban areas. User fees at the different levels of health care limit access to health care for poor people who are not able to pay. The problem of religious and other socio-cultural objectors to health services continues to persist, especially among the Apostolics who constitute about 30% of the population. There are inadequate specially designed services for new-borns and adolescents who are the most vulnerable and underprivileged and are the greatest contributors to morbidity and mortality. Therefore it will be imperative to design a tailored health service delivery system to address those sections of the society through: task shifting/sharing, strengthening the outreach programs, designing a more responsive and innovative health service delivery system for new-borns and adolescents and for the religious objectors. Most importantly, abolishing user fees for pregnant women and children of less than five years will be desirable. While this has been largely achieved at the primary care level, fees are often still charged at higher levels in the referral chain which is a major deterrent to seeking further care.

41 Health Development Fund Programme Document 2015

Continuum of Care: Disparities have been observed in service program is necessary. The use of solar energy coverages of interventions across health service delivery could be scaled up through partnerships with the private levels as well as across the life cycle. Although the lower sector and NGOs. health facilities usually provide fewer services in terms Community strengthening: Further strengthening of the of quantity and quality for various reasons including; role and operation of Health Centre Committees will be human resource gaps, skills gaps, attitude gaps among an important focus in the next phase so that health care the different levels, there is a realisation that the peri- providers are held to account but also supported in their urban poor communities have limited financial access to work, and form stronger links with the communities they the urban and tertiary health facilities, and are resorting serve. to other unorthodox care seeking behaviours. For similar reasons, clients referred from the lower health facilities for tertiary care do not comply because they are usually Gender: The HDF will focus on: required to pay for services at these facilities. Therefore, it may be necessary to extend the support from the HTF l Promoting gender equality and women and girls' to urban and tertiary facilities so that the free maternal empowerment through a national scale and child care policy can be effected at these levels as programme that alleviates barriers (including fees) to health care in pregnancy as a critical factor in well. There is need to further explore other mechanisms girls' vulnerability and inequality in society to mitigate the effect of user fees at the referral centres, including the possibility of using vouchers for referred l Men's role in RMNCH-A (such as through male clients. Similarly, the current implementation of champions) is emphasized community level interventions remains weak, and needs l Gender sensitive training for male and female to be strengthened to improve the coverage of community health workers including skills to evidence-based cost effective interventions to tackle social issues facing women, and complement the facility level interventions. Across the communication skills to support good maternal life cycle, it has been observed that newborns and nutrition and exclusive breastfeeding adolescents who contribute significantly to infant l Gender-based violence and sexual violence are mortality and maternal mortality respectively, are not recognised as public health issues, and a child receiving adequate health care the along the continuum protection priority affecting girls, boys and of care, and therefore need to be prioritised. It is also women, requiring support for forensic necessary to work on program integration, to be more examination recognized by the courts, access to treatment for HIV, emergency contraception and effective and to obtain better value for money. referral for welfare and legal services Integrating training and service guidelines, developing comprehensive supportive supervision tools, and l Ensuring age and sex disaggregated data in all providing integrated RMNCH-A services are some of the stages of the programme cycle (analysis, areas whereby program integration can be realized. implementation, monitoring, and evaluation) wherever required Further strengthening of infrastructure: Most of the l Cultural and Religious beliefs on early marriages health facilities lack reliable water supply and sanitation and non-use of contraceptives that will increase facilities, and electricity, and this could be included as the spread of HIV and AIDS, pregnancy another possible area of further support, although there complications to young women, psychosocial is scope to coordinate better with other sources of challenges and human rights abuses. support and funding; for example, through WASH activities and through Global Fund and GAVI support for health systems strengthening. In addition, strengthening Environmental conservation and Waste Management: communication and the referral system across all health Assist the sector to improve its waste disposal systems. service delivery levels, including with the village health

42 CHAPTER 6 Feasibility, Risks and Value for Money

A summary matrix of the risk management strategy is provided below. The existing strengths of the Zimbabwe Health system should be noted as important foundations for the feasibility of this programme. These include:

(a) Key government planning documents and strategies are in place

(b) A strong network of health partners exists in Zimbabwe working to improve the health sector

The risks to the programme will be addressed by the HDF partners, UNICEF and UNFPA.

Risk Probability Impact Mitigation Strategy

Increased political uncertainty Low High The UN and HTF donors have been able to 1 could lead to disruption of maintain good relations with the MOHCC during Programme implementation. previous instability and will continue to engage in regular dialogue. The UN will continue to support service delivery even during periods of crisis, as proven during 2007-9. The UN system will apply risk mitigating measures 23 to continue support should political uncertainty lapse into political instability.

2 Deterioration in the economy, Medium High The HDF will support the core functions of the resulting in further reduction in health system. The development partners and the government contribution to the UN will continue to advocate that the Government health sector. of Zimbabwe allocates more resources to health sector.

Utilize the national policy advocacy of CSOs under community accountability theme.

23 The UN system uses an Enterprise Risk Management system that clearly defines the risk levels for all its operations in the country.

43 Health Development Fund Programme Document 2015

Risk Probability Impact Mitigation Strategy

GOZ fails to implement required Medium Medium The DPs, UN and civil society will advocate for health reforms, in particular GOZ to provide funding to the urban and referral 3 elimination of user fees by facilities so that they are able to offer free facilities in the urban areas and services. The HDF will pursue the use of voucher referral facilities. system for referrals to higher level facilities.

GOZ fails to implement required Low - Medium Low 4 health reforms, in particular implementation of the recommendations that will come from the WISN study

Further outward migration of Low High HDF will support strategic HRH management and 5 Human Resources for Health. reform including workforce planning and review of the retention scheme to ensure that incentives target key cadres of health sector. HDF will continue to strengthen policies for retention of midwives, and training of cadres willing to provide services in the hard to reach populations of the country. HDF will continue to support RBF, retention scheme, reliable supplies, and improved supportive supervision which will increase staff motivation.

Government institutions have Low High Targeted technical assistance and capacity 6 limited capacity to implement building will be built into the HDF. programme components effectively

Persistent low utilisation of Low - Medium Low Targeted community mobilization, engagement 7 services by religious and other with opinion leaders, and gate keepers, targeted socio-cultural objectors. outreach services. HDF will support operational research to understand and address the barriers to access for these socio cultural groups.

Corruption, fraud and misuse of Low High The UN’s financial controls and accounting 8 funds procedures will be applied to provide adequate safeguards.

Make use of hybrid social accountability tools to root out corruption through the community participation theme.

44 Health Development Fund Programme Document 2015

Risk Probability Impact Mitigation Strategy

Overall costs of procurement of Low High The UN will apply the comprehensive 9 goods and services escalate procurement process which aims at procuring the beyond reasonable levels. best services and goods at the best cost across local and global markets.

Medium 10 Insufficient funding to cover all High The HDF will advocate for additional funding by the HDF pillars. other partners, and will encourage more donors to join the fund.

11 Industrial action or strikes by the Low High Assessment and clarity on the salaries, retention health workers allowances and remaining transparent in the different programmes.

Advocacy for adequate remuneration for the staff

Low Medium 12 Negative publicity on public Capacity to anticipate and respond to these health interventions, e.g. reactions. Orient media for anticipated events, Immunisation, key populations, prepare fact sheets in readiness to response, and mass drug administration prepare media response, training media on reporting on health.

Low - Medium Low 13 Transition of supply chain Careful planning, close monitoring, contingency management systems fund to close the gaps

Low Medium Adverse weather conditions and Disaster and risk management and preparedness, 14 natural disasters e.g. el nino multi sectoral responses at both national and leading to disruption of services community level. or increase in malnutrition

VALUE FOR MONEY will build on UNICEF’s track record of procurement for the HTF Medicines. UNICEF uses competitive tendering The HDF is building on the successes and lessons processes to obtain value for money in procurement of learnt from two major programmes which were drugs and commodities. Procurement of goods and implemented between 2012 and 2015 (HTF and ISP). services under the HDF will be done in accordance with Both programmes ensured that they had value for UNICEF’s procurement rules. money precepts in them i.e. economy, efficiency, effectiveness and equity. UNICEF and UNFPA will use its regular competitive procurement process for sub-contracting additional For the HDF these will be addressed as follows: implementing partners. There is a wide range of research institutions, private sector companies and non- government organisations in Zimbabwe, which could Economy respond to any competitive procurement process UNICEF and UNFPA will be responsible for procurement initiated by UNICEF, in order to ensure competition on of essential medicines and equipment in the HDF. This cost and innovation in delivery.

45 Health Development Fund Programme Document 2015

Efficiency UNICEF and UNFPA will establish baseline data and monitor unit costs at the key levels of the value for The HDF will mobilise additional resources for the money results chain. National Health Strategy, ensure coordinated use of resources, and reduce duplication of efforts and Financial and value audits will be undertaken within the transaction costs for donors and the MOHCC. The HDF UN parameters of internal audits. The terms of reference will strengthen alignment of donor support for national for the external evaluator of the HDF will include priorities, and allow restrictions that some donors may consideration of value addition and value for money. have on funding government staff, technical assistance, incentives or capacity building. The HDF is also in line with Paris Declaration on aid effectiveness principles of Equity harmonisation and alignment. The Programme is based on a situational analysis which The procurement of medicines and commodities by has reflected the gaps in access and quality of health UNICEF and UNFPA will have the economy of scale services for the mother and the child especially for advantage as they will procure almost the national RMNCH-A activities. The focus of the HDF is to provide requirements for the country. This will have the potential equitable services particularly to the hard to reach and of generating savings which can be ploughed back into to districts performing below expected targets. the Programme. The thrust of the value for money under the HDF will be on preservation of the gains which have been made by the earlier programmes. If these gains are not sustained Effectiveness they will be eroded. Any other Programme which seeks The pooled fund will allow national-scale health services to support the health sector will have to start from delivery to continue in critical areas despite the political where the other two programmes started in 2012. context. The mechanism provides strengthened Currently there is limited fiscal space for the government capacity in government to take on sector budget to take over and fund the activities which have support should the situation improve, while mitigating resuscitated the health systems for the country and risks. The activities to be funded by the HDF will be improved the well-being of the Zimbabwean directed by the national health strategy and communities. implemented using national guidelines thus ensuring the The framework and indicators for the VFM will be resources are used to support country priorities. developed and adopted before the start of the HDF.

46 CHAPTER 7 Monitoring, Evaluation and Reporting

A robust and realistic program monitoring system in support of the Health Development Fund (HDF) is essential for successful program management and implementation. The HDF will be monitored using the logical framework given in Annex 3. This reinforces evidence-based management principles, and empowers health sector managers at District, Provincial and National levels to collect and use data to track results and improve services. The framework identifies key questions to be answered, the data to be collected at specific points in time, and guidance on processing and analyzing the data.

The logical framework will further be refined to align with the National Health Sector Strategy. The indicators will be prioritized and rationalized by identifying most critical indicators (tracer indicators), thus ultimately reducing them to a manageable number. The cross-cutting issues (gender, social-equity, etc.) will be included in the log frame and gender disaggregation in some of the indicators will be incorporated.

An M and E framework will be developed with the operational work plan. These will have clear timelines and milestones and should be ready before implementation starts. The purpose of the HDF M and E framework will be to monitor implementation progress and provide continuous feedback to the MoHCC and HDF Steering Committee in order to strengthen, refine and improve program implementation. This will be done using indicators tracked through DHIS II and administrative reports. The framework will ascertain whether program objectives are on track, annual targets are being reached, services are reaching the target groups, will also identify any geographic variances, and assist HDF and health sector managers to identify and ameliorate implementation problems, making necessary changes to increase efficiency and effectiveness.

HDF monitoring will involves the following steps:

In principle there is no parallel monitoring structure which is specifically designed for HDF. The HDF will use the existing M&E system of the health sector. It will also continue supporting the national monitoring system and further strengthening the routine HMIS. The HDF has got a logical framework (see Annex 2). The sources of information and data to feed into the logical framework will include:

l PMD’s report, HMIS and other administrative reports The main data and information sources are: the monthly PMDs report and the routine HMIS. The PMDs monthly reporting format will be further improved to capture the information on HDF implementation status,

47 Health Development Fund Programme Document 2015

including achievements challenges and change attitudes and practices. A cornerstone of opportunities. Within the existing HMIS core supportive supervision is working with health staff indicators, those relevant to monitoring HDF to establish objectives, monitor performance, implementation status will be extracted regularly identify and correct problems on-site, and and analyzed. proactively improve the quality of service through mentoring and on-the-job training. At each level of health service delivery a supportive supervision l Vital Medicines Availability and Health Services team will be formed with a specific task using the Survey standard quality check list that the MoHCC has developed. These health facility based surveys are conducted quarterly to assess the status of medicines and supplies and services. The current VMAHS will be Annual Reviews, Mid-term review and Final revised to accommodate SRHR, commodities l Evaluation and services and the indicators that are tracked by the system and find ways of linking this survey On an annual basis the HDF will be reviewed. to the DHIS II system. Midterm Review and a final evaluation will be conducted by an independent evaluator in the second half of 2018 and 2020. These reviews will l Reports of Bi- annual and Annual review use data from MICS 2018 and ZDHS 2020. meetings Information from the reviews will provide guidance respectively for planning the second The HDF annual implementation plan will also be half of the programme and its impact. monitored using the routine 6 monthly and annual “plan and implementation review”, also known as Targets for the HDF have been set in consultation the “MODO,” which is conducted by the Planning, with the Ministry of Health and Child Care, in Policy and M&E Department of the MoHCC. alignment with the Health Sector Strategic Plan which is currently being developed. While aiming high, due considerations have been made for l Reports of a Joint Review Missions (JRM) committing to realistic and achievable targets, within the confines of financial and human Once a year, a Joint Review Mission composed of resource availability and other enablers such as a HDF Steering Committee members and other conducive policy environment and ongoing efforts relevant stakeholders will be conducted as part of to combat the negative influence of religious and the quality assurance system. Joint Review other socio-cultural objectors. Mission members will be divided into different groups and go out to all provinces of the country for a minimum of three days each to assess the HDF implementation status. JRM members will Reporting visit randomly-selected health facilities and will A reporting plan will be developed to outline key also conduct desk reviews with MoHCC health reporting events in the HDF cycle. The plan will include management officials at different levels. A annual reporting to donor's quarterly HDF Steering standard check list will be utilised and the Committees updates, as well as joint and independent findings of the JRM will be shared at the annual planning and review meeting by the HDF reviews. UNFPA will submit to UNICEF a report on coordinator. thematic area 2 and the other related areas, for consolidation in the annual report for the HDF. All contributing donors will receive one consolidated annual l Regular integrated supportive supervision narrative donor report each year covering the period in Moving from traditional, hierarchical supervision any one year up to 31 December. This annual narrative systems to more supportive ones requires donor report will include an annexed annual financial innovative thinking, national buy-in, and time to utilisation report which will follow the format set out by

48 Health Development Fund Programme Document 2015

the current HTF reporting format. Templates for the HDF managers and service providers - focusing on both annual report as well as for the quarterly HDF Steering National and Decentralized levels Committee updates will follow the current HTF format. 2. Development partners and donors to the health Each report will be drafted by UNICEF in consultation sector with MoHCC, UNFPA and key stakeholders. 3. Direct programme beneficiaries and the general In addition to the reports generated within UNICEF with Zimbabwean public; inputs from UNFPA, the Mid-Term Review, independent evaluation, regular joint review mission reports will be 4. Audiences abroad to provide a balanced view on consolidated and disseminated by UNICEF. HDF development in Zimbabwe

5. The media for behavior change communication.

Ensuring visibility of the HDF and its partners In addition to this it will make a concerted effort to bring through communication and advocacy. visibility to the whole sector and include other partners who are working in health but not necessarily in the A comprehensive communication strategy and plan to same areas as covered by the HDF. maximize the visibility of the HDF interventions, demonstrate the program’s vision of change and Each target audience has different stake/level of interest highlight its positive results achieved in improving the in the HDF programme and the content and tone of health system in Zimbabwe will be developed. The communication materials developed will be tailored to strategy will continue to provide a coherent overview of address key messages to each audience. Various media HDF support to the Zimbabwe health sector as the channels will be used including popular social media, transition is made from the Health Transition Fund to print media, TV and radio, technical and policy briefs. Health Development Fund. It will aim at improving the Other channels will be considered as deemed knowledge, perceptions, and practices of key target appropriate for the message. As well as taking audiences with regards to the programme objectives by: advantage of high profile national events, HDF will l Sharing with program stakeholders and organize special launch events, exhibitions and press beneficiaries a common vision and understanding conferences. Messages will also be developed as of the program goals, objectives, and expected stickers on materials supplied by the HDF. A specific results; visibility five year plan for visibility will be developed in the first six months of the HDF implementation. l Actively mobilizing program stakeholders and beneficiaries to support and engage with program activities; l Sustainably adopt and apply new processes, protocols and behaviors promoted by the program; l Promoting increased government of Zimbabwe engagement and capacity to implement and sustain project activities in future. l Sources of funding to be acknowledged in all communication and advocacy which makes reference to the HDF.

Target audiences will include:

1. The government of Zimbabwe policy makers,

49 CHAPTER 8 Programme Management 24

It is proposed that the Health Development Fund will mainly be a multi-donor pooled fund. The HDF will provide support across the full range of health services whilst continuing to provide key support to RMNCH-A, SHRH and nutrition services, and enhance equity in health care availability. The focus will be on consolidating the gains made at the primary care level and in district hospitals, with a possible move to selected support at provincial level. Development partners will be encouraged to apply the majority of their health sector support to a pooled fund under the guidance and leadership of the Ministry of Health and Child Care and all other partners with the same objectives willing to work under one strategic plan, one coordination mechanism and one monitoring and evaluation plan. The MoHCC will build on the success of the current HTF Steering Committee and establish a HDF Steering Committee that incorporates representation from all key stakeholders (whether pool funders or not).

The modalities of governance are indicated in the box below.

ENSURING TRANSPARENT GOVERNANCE IN THE HEALTH DEVELOPMENT FUND

l The HDF programme is developed through a highly consultative process (including MoHCC planning and reviews, aid coordination unit discussions and collaborative work planning). l Donor and UN Agreements outline commitment to log frame and budget allocations within the programme budget allotment (PBA) and corresponding proposal. l Only the Steering Committee has the authority to make changes to the log frame and budget allocations. l A technical team/task force per each thematic area will support the Steering Committee decision making process. l A coordination unit will be established at the MoHCC, with One HDF co-coordinator and one HDF assistant coordinator to ensure alignment with MoHCC plans and assist in sharing information with all partners. l Contractors will be selected through a transparent and competitive tender process guided by UNICEF. Terms of Reference will be approved by the Steering Committee. A review panel selected from the HDF SC members will be requested to review the bids. The contracting of implementing partners will be done by UNICEF. l Independent reviews will occur throughout implementation, including: Regular joint annual reviews, a mid-term review, a final evaluation 27 See Annex 3 for the strategic l Transparent communications strategy will ensure public availability of key documents, roles of HDF partners including web-based materials.

The outline of the management structure of the HDF is presented in the Figure below.

50 Health Development Fund Programme Document 2015

HEALTH DEVELOPMENT FUND GOVERNANCE OUTLINE

Health sector review and planning group

HDF e STEERING COMMITTEE v i t (Co-chaired by MoHCC Permanent n C

e Secretary and Donor Representative P v F e Members include: Funding Partners, N r Z P UN Agencies, Ministry of Finance,

d

D Ministry of Women’s affairs and Gender, n P

a Health Services Board, World Bank, d

M USAID, CDC, CCM Member, Civil Society n a R

Representatives, Private Sector, Other A e

v Health Stakeholders, one PMD and the H i t

P three Principal Directors (Family a T r Health, HR, Pharmacy, Nursing and A u N C Quality)

D P

6: Health Policy, Planning, M&E and Coordinaon and QA/QI

Principal Director Policy and Planning, Monitoring and Evaluation

HDF COORDINATION UNIT

and QA/QI

OTHER RELEVANT COMMITTEES

51 Health Development Fund Programme Document 2015

The diagram above provides the management structure within the MoHCC convenes a consultative meeting at for which the HDF will be coordinated and managed the end of the year that involves all Departments, with with the HDF Steering committee taking a central role in national and provincial health staff, and funding and the decision making processes. In summary, the technical partners. The participants review the status of technical committees will work with the respective health for all Zimbabweans and determine a set of Directorates listed in the diagram, to ensure that all the prioritized actions for the following year. These actions technical input and knowhow is built into the decision are detailed and costed in a Performance Contract that makers of the Ministry. It is planned that the Directors the Permanent Secretary MoHCC signs with the Office contribute to the monthly steering committee meetings of the President and the Ministry of Finance. The of the HDF. The technical committees are considered as Performance Contract is in-built into the MoHCC Annual critical in the running of the HDF will be supported by Plan. the HDF to ensure that they are functional where this is Broad policy dialogue and aid coordination are necessary under the planning component of the HDF. addressed within the Health Sector Review and The Funding Partners, UNICEF and UNFPA will Planning Group, chaired by the Minister of Health and contribute to the technical discussions in the technical Child Care with the deputy chair appointed from among committees. This will assist in ensuring that when the development partners. The Health Sector Review and Steering Committee meets, discussion will be limited to Planning Group is composed of senior-level strategic issues. In addition to this, the Funding representatives from bi-lateral and multilateral agencies Partners, UNICEF and UNFPA will attend the Steering and development banks. The Group’s mandate is to (i) Committee meetings. The Partners, together with support MoHCC ownership and leadership in the health UNICEF and UNFPA will be able to meet outside the sector, and encourage strong MoHCC-led coordination Steering Committee to discuss implementation and of funding partners; (ii) promote coordinated sector-wide funding issues. The Funding Partners will also be able to policy dialogue and technical support on strategic hold separate meetings to guide on funding possibilities. issues in health; and (iii) ensure that the support of The roles of the Policy and Planning, Monitoring and funding partners to health is provided to MoHCC in a Evaluation Division of the Ministry of Health and Child regular, predictable, harmonized and coordinated Care, will ensure that the activities funded under the manner. HDF follow the guidelines and strategies of the Ministry of Health and Child Care and ensure that the activities The Permanent Secretary of the MoHCC will chair the are monitored within the MoHCC structures. The HDF Steering Committee, co-chair jointly with one of Division will also be expected to house the coordinator the HDF Funding Partners. The MoHCC Principal and the assistant coordinator of the HDF and provide Director, Policy and Planning, Monitoring and guidance where necessary. It is the role of the HDF Evaluation, will provide leadership in the development of Steering Committee to take the issues and challenges annual implementation plans and the monitoring of the which need the Minister's input to the Health Sector outputs of the HDF as part of his role in the MoHCC Planning and Review meetings. planning, monitoring and evaluation. The three principal directors shall be members of the Steering committee The specific roles for each of the stakeholders in the and so will be the executive director of the HSB, management and coordination of the HDF are outlined executive director of NatPharm and ZNFPC. The below: following directors will also be members of the steering committee: Family Health, Human resources, Pharmacy 8.1 Ministry of Health and Child Care (MoHCC) and Nursing.

It is the role of the MoHCC to take leadership in The implementation of the HDF will be further supported directing the health sector through national planning and by the National Maternal, Newborn and Child Health review processes which articulate national priorities, Steering Committee (RMNCH-A SC), chaired by the strategies and operational objectives. The Directorate Honorable Minister of Health and Child Care. The of Policy, Planning, Monitoring and Evaluation (PPPME) RMNCH-A SC will be technically supported by the National Reproductive Health Steering Committee

52 Health Development Fund Programme Document 2015

(RHSC) and the Child Survival Technical Working Group plans by end of December each year for (CSTWG). The RHSC and CSTWG are comprised of implementation the following year. Government ministries, development partners, civic l Ensure all contracted implementing partners in society, and research and training institutions. RMNCH-A comply with HDF planning and reporting requirements 8.2 HDF Funding Partners Funding partners to the HDF (Currently: Canada, DFID, 8.3 HDF Steering Committee EU, Irish Aid, Norway and Sweden and other new The HDF Steering Committee will be responsible for the funding partners including GAVI) will provide un- oversight and decision making of the HDF. The HDF earmarked financial support necessary to fully Steering Committee will be composed of MoHCC, implement the coordinated interventions set out in the Principal directors and directors relevant to the HDF Programme Document, and make timely transfers programme components, one provincial medical of funds through the agreed-upon pooled funding director, Funding partners to the HDF (Canada, DFID, mechanisms. Funding partners will strive to ensure the EU, Irish Aid, GAVI, Norway and Sweden), UNICEF, predictability of their financial support by informing the UNFPA, WHO and other UN agencies, Ministry of MoHCC and other partners of the support they Finance, Ministry of Gender,Women’s affairs and anticipate providing. Community Development, Health Services Board, Within their capacity Funding Partners will provide NatPharm, Zimbabwe National Family Planning Council, technical support in the different thematic areas and World Bank, USAID, CDC and a civil society eventually "ad hoc" financial resources for specific representative for the local NGOs and for the intervention related to monitoring and evaluation, international NGOs, UNICEF, WHO and UNFPA will population surveys, financial reviews. serve as technical advisors with UNICEF as the Secretariat. On an annual rotation basis the Funding Partners will select a HDF Steering Committee Co-chair. The Steering Committee will be co-chaired by the Permanent Secretary of the MoHCC and a Funding All Funding Partners irrespective of their financial Partner. Funding partners will on an annual basis select participation quota have the same rights and duties a funding partner to serve as co-chair of the HDF within the HDF decision process and visibility. steering committee. The HDF steering committee will initially meet monthly (this could be changed to every other month or quarterly as implementation progresses). The role of HDF Funding Partners includes, but will not be limited to: The role of the HDF steering committee includes, but l Align funding support to MoHCC priorities; will not be limited to: l Communicate with the GoZ regarding their annual l Approving funding allocations to thematic areas and multi-annual commitments in order that the and related activities in accordance with the HDF GoZ can plan and provide services accordingly; annual plan and budget. l Recognize the importance of timely disbursement l Ensuring alignment of HDF allocations with the of funds and work towards ensuring that financial MoHCC Performance Contract/Annual Plan within disbursements are made according to a schedule the thematic areas agreed upon in the agreed with the GoZ; Programme Document. l One system for technical reporting, procurement, l Approve reallocation of funding across thematic financial accounting, and auditing of programme areas, across agencies, between implementing expenditure; partners, among activities based on shifting priorities and performance l Conduct joint missions related to the HDF in order to minimise the burden on MoHCC; and l Approving terms of reference for implementing partners. l Review and approve annual budgets and work

53 Health Development Fund Programme Document 2015

l Participating in tender review committees and governing the receipt and administration of approving selection of implementing partners in contributions, and will report on the use of funds accordance with UN rules and regulations. pursuant to parameters established within the agreements signed with each funding partner. UNICEF Review and approve the terms of reference, l will prepare and maintain a treasury plan to ensure scope of the mid-term review, including the report timely replenishment of the HDF account, showing likely l Reviewing and approving the end-of-year cash-flow requirements for the programme over the programmatic and financial progress report course of the year. submitted by UNICEF and UNFPA. The programme report will present results-based A reporting plan will also be developed to outline key progress against the log frame indicators. reporting events in the HDF cycle. The plan will include annual reporting to donors, 6 monthly donor updates, as Agreeing on the scope and timing of the Joint l well as joint and independent reviews. By 31 January of Annual Reviews. every year, UNFPA will submit to UNICEF a report on thematic area 2 and parts of thematic areas 3 and 7, for consolidation in the annual report for the HDF. All 8.4 UNICEF contributing donors will receive one consolidated annual UNICEF will have two distinct roles in the HDF- as fund narrative donor report each year covering the period in holder and programme coordinator/manager. A number any one year up to 31 December to be circulated to the of safe-guards will be put into place to ensure donors. This annual donor report will include an transparency and segregation of duties as necessary. annexed annual financial utilisation report. The financial As fund manager and programme coordinator/manager, utilisation report will follow the format set out by the UNICEF, under the oversight of the Steering Committee contributing donors and will be in line with key will be responsible for: institutional agreements. Templates for the HDF annual report as well as for quarterly Steering Committee Ensuring overall financial management and attainment updates will follow the current HTF format. Each report of programme results across all thematic areas. This role will be drafted by UNICEF in consultation with key will include responsibility for the appropriate use of stakeholders and MoHCC colleagues and will be funds as well as the performance of contractors and submitted to the donors by the 31st April of every year. HDF implementing partners. Using the in-country management HDF budget line, UNICEF will ensure In addition to the reports generated within UNICEF, Mid- sufficient technical and operations capacity exists to Term Review (report with recommendations), and manage risk, supervise contractors and ensure independent evaluation as well as regular joint annual accountability for the HDF resources and results. review reports will be reviewed and disseminated by UNICEF. UNICEF as Administrative Agent will sign an inter agency agreement with the participating organization UNICEF will arrange for its financial records to be (UNFPA) enabling UNICEF to transfer funds to UNFPA audited in accordance with the established procedures and allocating technical and reporting responsibilities to and appropriate provisions of the financial regulations UNFPA for the pillars that are going to be implemented and rules of the United Nations and UNICEF. with UNFPA support. Procurement of goods and services under the HDF programme will be done in accordance with UNICEF’s UNICEF and UNFPA will support the MoHCC with Procurement Rules. technical and implementation capacity in respective thematic areas as required and in building capacity for The HDF Coordinator and an assistant will be based in overall financial and programme management of such the MoHCC they will play a key liaison role between the funding mechanisms. MoHCC, the HDF Steering Committee and UNICEF, UNFPA and the Funding Partners. The HDF Coordinator UNICEF will sign a standardized agreements with each will assist in coordination, smooth communication and funding partner setting out the terms and conditions real time updates.

54 Health Development Fund Programme Document 2015

8.5 UNFPA colleagues and this should be submitted to UNICEF by 28 February of every year. UNFPA will be responsible for thematic area 2, SRHR and any other areas where they have a comparative UNFPA will participate and contribute to the Mid-Term advantage identified by the HDF Steering Committee. Review, independent evaluation as well as regular joint UNFPA will have the oversight of the financial annual review activities as directed by the HDF Steering management and attainment of programme results on Committee. the designated thematic area. This role will include UNFPA will arrange for its financial records to be responsibility for the appropriate use of funds as well as audited in accordance with the established procedures the performance of contractors and HDF implementing and appropriate provisions of the financial regulations partners. UNFPA will also support the MoHCC with and rules of the United Nations and UNFPA. technical and implementation capacity in the designated Procurement of goods and services for thematic areas thematic area as required and in building capacity for 2, and the other relevant areas will be done in overall financial and programme management of such accordance with UNFPA’s Procurement Rules. funding mechanisms.

Participating partners have appointed UNICEF as Administrative Agent. This means that the 8.6 Implementing Partners Administrative Agency and the participating UN Although the majority of the HDF activities will be organization (UNFPA) will sign the standard inter agency implemented by the MoHCC, specific components may agreement with UNICEF setting out the terms and be delivered by academic or research institutions, conditions governing the receipt and administration of private sector companies, UN agencies, or non- contributions, and will report on the use of funds governmental organizations using the UN tender or pursuant to parameters established in the programme partnership cooperation agreement procedures. document. 25 UNFPA will prepare and maintain a cash flow plan to ensure timely replenishment of the thematic area 2 and other relevant pillars, showing likely cash- 8.7 Non-UN Implementing Partners flow requirements for the programme over the course of UNICEF and UNFPA will enter into agreement with the year. implementing partners as per their programme and financial policies and procedures to manage specific A reporting plan including a financial report will be components of the HDF, as agreed upon by the HDF provided for thematic area 2, and other relevant pillars Steering Committee. Contractors will provide standard outlining key reporting events in the HDF cycle. The plan quarterly, semiannual and end of year narrative and will include annual reporting to donors, quarterly financial reports. HDF will follow UN procedures for all Steering Committee updates, as well as joint and the activities to be implemented in the HDF. independent reviews. UNFPA will submit to UNICEF a report on thematic area 2 and on other activities undertaken by UNFPA under other relevant pillars, for 8.8 UN Implementing Partners consolidation in the annual report for the HDF. All Should the Steering Committee select additional UN contributing donors will receive one consolidated annual agencies other than UNICEF and UNFPA as narrative donor report each year covering the period in implementing partners, provision will be made for pass- any one year up to 31 December. This annual donor through or bilateral agreements. In both cases standard report will include an annexed annual financial utilisation UN agreements between UN partner agencies or report. The financial utilisation report will follow the between donors and UN agencies will be utilised. 26 format set out by the contributing donors and will be in line with key institutional agreements. Templates for the HDF annual report and the quarterly updates will follow 25 In the pass-through mechanism, UNICEF would charge 1% administration fee for administering funds the current HTF. Each report will be drafted by UNFPA 26 In the pass-through mechanism, UNICEF would charge 1% administration in consultation with key stakeholders and MoHCC fee for administering funds and UN agencies receiving funds would charge the prevailing recovery rate.

55 CHAPTER 9 Programme Co-ordination

Inter Sectoral Coordination and building synergies: The links with other programmes and support to the health sector are well recognized, particularly in HIV and AIDS; TB; Malaria; Nutrition; Sexual and Reproductive Health; Water, Sanitation and Hygiene (WASH), Education and Social Protection. The HTF to date has encouraged strong links across sectors and sub-sectors and will continue to do so while extending this coordination to a more formal approach that is more inclusive and encourages greater participation of other key stakeholders through the governance mechanism that has been so effective.

The HDF will use the multi-sectoral community based nutrition model as a practical example of working across sectors.

All the members of the Steering Committee will make a concerted effort to report at the beginning of each year the activities that they are funding including those that are being implemented through NGOs. The technical committees under the

56 Health Development Fund Programme Document 2015

MoHCC will be required to provide a summary of the stakeholders. The following institutions/bodies are activities which NGOs are doing in the specific areas currently participating in the HTF Steering Committee covered by the technical committees. and they are expected to also be represented in the HDF Steering Committee: The Ministry of Finance, The HDF internal coordination will be carried out by the Health Services Board, WHO, UNDP, UNAIDS, World HDF Coordinator, with the responsibility to monitor, that Bank, USAID, CDC, GF-CCM, RBF-national steering approved plans and related actions are fully committee, Civil Society Representatives and Private implemented. The HDF Coordinator will also be Sector representative. responsible for the communication with HDF Funding and Non-funding Partners. He/She will facilitate the The wide participation of the health stakeholders in the coordination of the different partners of the HDF HDF Steering Committee meetings ensures the flow of including UNFPA, UNICEF and the donor agencies on information especially in relation to the HDF adopted behalf of the Ministry of Health and Child Care. The strategies and implemented actions. It will also share HDF Coordinator will also be responsible for writing the with partners challenges and lessons learned. In minutes of the HDF Steering Committee meetings and addition during all steering committee meetings, for organizing the logistics of the Joint Annual Review. partners non-financing the HDF are requested to Due to the increased thematic areas covered by the provide a short presentation of their plans and HDF, he/she will be supported by a HDF Assistant achievements. Coordinator. The Global Fund due to the common areas of support The Coordinators will be based in the Ministry of Health that it has with the HDF will have a standing item on the and Child Care where they will have a coordination unit. HDF agenda through the CCM, and it the same way The terms of reference including the resourcing for the HDF will be a standing item on the agenda of the CCM. coordination unit, will be established before the HDF In this way coordination and information flow between starts functioning. The terms of reference will be based two of the major funding streams in health will be on the HDF structure and lessons learnt from other effected. GAVI funding will be managed through the pooled funding mechanisms. HDF, and will therefore be monitored by and reported to the HDF Steering Committee. The HDF, like the HTF, is by "de facto" one of the major health co-ordination platforms of the health system in The HDF aid modality being similar to a SWAP Zimbabwe. For this reason the HDF Steering Committee mechanism and fully aligned and embedded to the in addition to its core members (MoHCC, Funding Zimbabwe National Health Policy represents the basis Partners, UNICEF, and UNFPA) is open to the for a model of the whole health sector co-ordination. participation of other relevant health sector

57 CHAPTER 10 Resourcing the Health Development Fund

Government health expenditure in Zimbabwe has recovered significantly since the near economic collapse in 2008/9. Since 2008, total government expenditure on health has increased from less than US$60m, to US$313.6m in 2014. This is an increase in government health per capita spending from just over US$5 to about US$23 in 2014, and shows strong commitment to health, especially at a time where fiscal space remains very tight.

Although the commitment from the Government of Zimbabwe to continue strengthening the health system is commendable, there are challenges that continue to hinder sustainable public sector health financing over the short to medium term. Some of these include: Lack of policy clarity, low investment levels into the economy, significant levels of national debt, and a general slowdown in regional and global economic performance. These factors, and others, have continued to constrain fiscal space and have made it difficult for the government to fund non-wage expenditures in critical social sectors such as health, or to fund health priority areas such as medicines and medical supplies, maternal and child health, NCDs and nutrition. Zimbabwe’s current health expenditure per capita thus remains far below what would be necessary for the health sector to meet its basic health MDG targets. At the current level of expenditure of around US$23/capita, increased spending is still required to meet the WHO recommended spending level. In 2009, The WHO Task Force on Innovative Financing revised the US$34 per capita recommended by the Macroeconomic Commission in 2001 to US $ 44. This would have to increase to US $ 60 in 2015. In view of the heavy burden of HIV, TB and NCDs, this upward revision is particularly relevant for Zimbabwe. Using the projected population, in 2015, Zimbabwe should be spending about US$ 930m annually on health which is three times the current level of expenditure. Despite this, the calculation of resource requirements is undertaken taking into account the historical spending levels, the absorptive capacity, the constrained fiscal space and what can realistically be raised by donor partners and sustain the significant impact achieved so far.

27 MoF Budget Statement, November 2014.

58 Health Development Fund Programme Document 2015

40 35 30 WHO recommended level $

25 S

U 20 15 Per capita 10 5 0 2009 2011 2012 2013

Figure 14: Trends in per capita spending in health Figure 15: Health sector expenditure comparisons

Despite the increased expenditure from 2008; as a pledged to increase the proportion of government percentage of GDP, government health expenditure in expenditure towards health to 15% of total budget. Zimbabwe still lags behind that of sub-Saharan Africa These are major advocacy issues being taken up with and of other low-income countries, as depicted in figure the Ministry of Finance by MOHCC and will continue to 15 above. The current proportion of health expenditure be discussed and flagged by the HDF Steering also falls significantly below the Abuja declaration committee and the Review and Planning group for agreement, where Zimbabwe and other signatories discussion in parliament.

80 40 70 District Rural and Mission Hospital 35 60 Rural Health centers 30

50 Government (Target) 25 Government (Actual) 40 HTF (Actual) 20 30 15 20 10 10 5 0 Local Insurance Domestic Central External User Fees 0 government Donations Government Donors Drugs Government Government HTF (Target) (Actual) (Actual) Figure 16: Sources of Health Sector Revenue Figure 17: Medical Supplies and Services Expenditure

59 Health Development Fund Programme Document 2015

More than 70% of rural district and mission hospitals Estimating total health expenditure revenue, excluding salaries, is provided for by donors; requirements in Zimbabwe in 7 thematic and in 2013, central government was able to provide areas, 2016-2020 US$6.7m towards medical supplies and services To estimate the required spending on key interventions, expenditure, compared to donor contributions of health expenditure needs were determined based on the $17.5m. Donor funds and out of pocket expenses level of spending per capita necessary to catch up on largely from poor households continue to be a critical basic health. A total health expenditure target of input is sustaining the gains made in reducing maternal US$42/capita in 2020 (from GoZ and DPs) is projected. and child mortality. Therefore, despite the commendable This target is still far below the expected per capita of commitment by GoZ towards improving the health US$60.00. Under this scenario, health expenditure in sector through increasing investment in the sector Zimbabwe will initially rise to approximately within a constrained fiscal environment more still need US$42/capita in 2020 and then as DP contributions to be done to sustain the gains. It is necessary still vital start to be phased out, total health spending per capita will trend towards the WHO recommended level and be that donor funds continue to flow into the sector in the largely funded by GoZ. short to medium term to safeguard the investment in health and preserve the gains realized in the sector thus The total health funding requirements are assumed to far. In this way out of pocket expenses for the vulnerable increase smoothly from 2014 levels to the level required groups can reduced. to achieve the macro target of US$42/capita in 2020.

(2%) (1%) (2%) (4%) (18%) MOF HTF WB USG (42%) GAVI (13%) ISP PEPFAR GF GF (6%) USG GF USG-PMI (8%) (2%) (1%) (1%)

2014 Health Sector Funding - showing proportions of the different partners to the health sector in 2014

60 Health Development Fund Programme Document 2015

For this target of US$42/capita to be achieved, total Resource requirements for seven HDF thematic expenditure on health in Zimbabwe would need to be areas 2016-2020 approximately US$597m 28 . In 2014, public health The financial resource requirement for the HDF for the expenditure was reported as US$313.6m and DP 29 seven thematic areas between 2016 and 2020 is based contributions were US$181.6m 30 . Of this combined on what is estimated to be the funding gaps in the expenditure, between 63% and 67% of this was sector. The total financial envelope required to meet the incurred in the six thematic areas by GoZ and selected set targets is USD681.91 Million and the detailed budget DP. Based on this macro expenditure, target expenditure is given in Annex 2. amounting to approximately US$597m in 2020, and that approximately 63-67% of this will go towards the 6 This works on a central assumption that the resource thematic areas addressed in the first phase of HTF. The requirements can be pooled fund in 2016 to 2020 and total required expenditure in the 6 thematic areas, 2016- will maintain the momentum so far built by the different 2020 is shown in table 4 below. This calculation is programmes mentioned in this document moreso the based on the total health expenditure needed to achieve HTF and the ISP. It has a realistic chance of achieving a per capita expenditure of US$42 in 2020, apportioned the targets described earlier and summarized in Annex 1 to the 6 thematic areas based on their share of total below. On average, the pooled fund requires US$136m health expenditure in 2014. 31 The figures in the table per annum to deliver the targets. Should this not be include all of the salary budget, most of the mobilized, it will be necessary to revise the targets. commodities 32 and expenditure in capital required to improve M&E systems in the short term.

Table 4: Estimated total required health expenditure in the thematic areas, 2016-2020

Thematic Area 2016 2017 2018 2019 2020 Total

Commodities and Technologies $67.96 $70.00 $72.10 $74.27 $76.49 $360.82

Sexual reproductive health 33 50 50 50 50 50 250.00

RMNCH-A Service Delivery $17.79 $18.32 $18.87 $19.44 $20.02 $94.44

Human Resources for Health $183.43 $188.93 $194.60 $200.44 $206.45 $973.85

Finance (RBF) $18.87 $19.44 $20.02 $20.62 $21.24 $100.19

Policy, Planning, M&E and Coordination $46.07 $47.45 $48.88 $50.34 $51.85 $224.59

Technical Support and Innovation $4.00 $4.12 $4.24 $4.37 $4.50 $21.23

Total $388.13 $398.27 $408.72 $419.48 $430.55 $2,045.12

28 Projected population in 2020 is 14.2m. This is based on a historical annual population growth average of 1.1% witnessed between the 2002 and 2012 national cen - sus. 29 Official Development assistance 30 MoF annual budget statement, December 2014 31 These six thematic areas constituted approximately 67% of the total health expenditure in 2014. This ratio was then applied to the total health expenditure in 2020 sufficient to achieve a per capita expenditure of $42 from Goz and official development assistance. 32 It is assumed that adequate commodities funding for the HIV / AIDS, TB, and Malaria programmes will be available from multilateral funds and non-pooling DPs. 33 Estimated figures not readily available

61 ANNEXES

ANNEX 1: MIMS 2009, DHS 2010 AND MICS 2014 INDI - CATOR TRENDS AND HDF BASELINES

MICS 2014 HDF Log MIMS DHS Indicator (HDF frame target 2009 2010-11 baseline) 2020

Maternal Mortality Ratio (MMR) per 1000,000 live births - 960 614 35 350

Neonatal Mortality Rate (NMR) per 1,000 live births - 31 29 25

Infant Mortality Rate (IMR) per 1,000 live births 67 57 55 8

Under-Five Mortality Rate (U5MR) per 1,000 live births 84 84 75 65

Proportion deliveries with Skilled Birth Attendance 60% 66% 80% 85% (SBA)/ facility deliveries Proportion of pregnant women attending at least 4 57% 65% 70% 8 0 % ANC visits Proportion of women who received PNC within 2 days - 27% 77% 80% of delivery

Unmet need for family planning - 13% 10.4% 6.5%

Adolescent fertility rate - 124 120 115 36

Percentage of infants aged 12-23 months fully 36% 65% 69% 75% immunized Percentage of infants exclusively breastfed (EBF) 26% 31% 41% 45% (0-6 months)

Prevalence of stunted children - 32% 28% 19%

Proportion of under-5 children with ARI symptoms - 31% 34% 45% treated with antibiotics Proportion of under-5 children with diarrhea treated - 63% 56% 37 60% with ORT Proportion of under-5 children with diarrhea treated - - 14% 30% with ORT and zinc

34 Some of the targets have been adjusted slightly downwards in view of the diminishing donor funding contributions. The HDF targets will be revised and only finalized in alignment with the National Health Sector Strategy targets once the latter has been completed towards the end of the year. 35 Deaths during pregnancy, childbirth, or within two months after delivery or termination of pregnancy, per 100,000 births within the 7-year period preceding the survey; the value was 581 for deaths within the 5-year period preceding the survey 36 Subject to revision according to new ASRH strategy 37 Treated with ORT and continued feeding

62 Health Development Fund Programme Document 2015

ANNEX 2: DETAILED BUDGET

Thematic Area 2016 2017 2018 2019 2020 Total UNICEF COMPONENT

1. RMNCH-A Service Delivery 4.97 5.07 4.95 4.8 4.62 24.41

3. Medicines, Commodities (including Nutrition 26.09 27.57 28.79 30.02 31.27 143.74 commodities) and Technologies

4. Human Resources for Health 14.53 13.28 11.92 14.11 16.39 70.23

5. Finance (RBF) 11.07 11.32 11.42 11.51 11.58 56.9

6. Policy, Planning, M&E and Coordination 4.97 4.87 3.99 3.02 1.94 18.79

7. Technical Support and Innovation 4 4.12 4.24 4.37 4.5 21.23

Sub-Total for Thematic areas 65.63 66.23 65.31 67.83 70.3 335.3

Programme Management Costs 5.5 5.5 5.5 5.5 5.5 27.5

Total Programmable Budget 71.13 71.73 70.81 73.33 75.8 362.8

7% Recovery Cost 4.98 5.02 4.96 5.13 5.31 25.40 UNICEF Total 76.11 76.75 75.77 78.46 81.11 388.20

UNFPA COMPONENT

1. RMNCH-A $3.00 $3.50 $3.50 $3.00 $2.00 $15.00

2. SRHR $21.00 $23.00 $23.00 $22.00 $21.00 $110.00

2a unfunded MC programme catch-up phase $16.00 $31.00 $28.00 $75.00

3. Medicines, Commodities and technologies $13.00 $13.00 $13.00 $13.00 $13.00 $65.00

7. Technical Support and Innovation $0.50 $1.00 $0.50 - - $2.00 Sub-total for Thematic Area $53.50 $71.50 $68.00 $38.00 $36.00 $267.00 Programme Management Costs[1] $1.50 $1.50 $1.50 $1.50 $1.50 $7.50

Total Programmable Budget $55.00 $73.00 $69.50 $39.50 $37.50 $274.50

7% Recovery Cost $3.85 $5.11 $4.87 $2.77 $2.63 $19.22 UNFPA Total $58.85 $78.11 $74.37 $42.27 $40.13 $293.72 GRAND TOTAL $134.96 $154.86 $150.13 $120.73 $121.23 $681.92

1a) Paediatric HIV and AIDS* 2.6 3.5 3.1 3.0 2.7 14.90

*This budget line is provide for information, its not included in the total budget for the HDF **GOZ to provide its commitment in the Health Development Fund.

63 Health Development Fund Programme Document 2015

ANNEX 3: LOGICAL FRAMEWORK

Attached separately

64

66